Key Points US-born English-speaking free clinic patients reported higher level of depression and a higher number of somatic symptoms than non–US-born English or Spanish-speaking free clinic patients. Non–US-born English-speaking free clinic patients reported lower levels of depression and fewer somatic symptoms than Spanish-speaking free clinic patients. Somatic symptoms and perceived neighborhood satisfaction were related to depression among free clinic patients. Free clinics, which were founded in 1967, provide free or reduced-fee health care to individuals who lack access to primary care and are socioeconomically disadvantaged.1–3 It is estimated that 1200 free clinics currently operate throughout the United States.1 Free clinics are an important safety net for those who otherwise do not have access to primary care by providing medical care and assistance in daily life functioning to patients who are either underinsured or uninsured, have a low or no income, and are at risk for increased physical and mental health concerns.1–4 Free clinics usually rely on volunteer staff and have unstable financial resources.2,3 Depression represents a serious health problem for free clinic patients.4–6 Risk factors for depression include poverty, early life stress, genetic factors, and environmental factors.7–10 Although 10% of primary care patients report depression in comparison with 20% of free clinic patients, most patients go untreated.5,11 Minority patients are especially prone to live without treatment because of numerous barriers associated with receiving mental health services. This study focuses on understanding how somatic symptoms and perceived neighborhood environmental factors may influence depression among free clinic patients. Somatic symptoms (eg, stomach pain, back pain) are medically unexplained chronic or disabling physical symptoms.12 Somatic symptoms can be associated with undiagnosed mood disorders or depression13–15 because primary care patients tend to seek health care for physical conditions. These symptoms can represent the presence of important mental health problems found commonly within Latino and Asian populations in the United States.12 In previous work by McIntyre and colleagues, depressive symptoms decreased when clinicians focused on addressing somatic symptoms in treatment.15 The causal relation of depression and somatic symptoms has received mixed support in the literature and requires further examination. Another factor to consider is perceived neighborhood context, which has been associated with a person’s overall health status and impact on sleep quality.16 Perceived neighborhood context was found to be negatively related to physical and mental health when the neighborhood was described as a stressful environment.17 Moreover, one’s perceived neighborhood environment can contribute to depressive tendencies. Neighborhood stressors (eg, perceived or actual violence) were correlated with increased depressive symptoms in several studies.18,19 More research is needed to examine the direct connection between depression and the perceived neighborhood environment of patients attending free clinics. The purpose of the study was to investigate the impact of somatic symptoms and perceived neighborhood environment on depression by a comparison between US-born and non–US-born free clinic patients. This study should contribute to increasing knowledge about community-based primary care interventions on depression and expand the literature on culturally diverse, immigrant, and socioeconomically disadvantaged patients being served in a free clinic setting. Methods Overview The current community-based research project was conducted at a free clinic in the intermountain western United States. The clinic staff collaborated with the research team by supporting the development of the survey instrument, study protocol, participant recruitment strategies, and interpretation of study results. The clinic, which served as the data collection site for this study, provides free healthcare services (eg, routine health maintenance, preventive care) for uninsured individuals from both urban and suburban areas. The free clinic has no affiliation with religious organizations, is funded by nongovernmental grants and donations, and has been in operation for more than 7 years. The clinic is staffed by six full-time paid personnel and more than 250 active volunteers and is open five days/week. In 2012, there were 15,209 patient visits. To qualify for services at the clinic, an individual must live below the 150th percentile US poverty level ($35,325 for a family of four members in 2013) and not have access to employer-provided or government-funded health insurance. Data Collection and Participants Before the data were collected, the institution’s review board approved this study as an exempt protocol. The data were collected several times per week (1–2 hours each time) for 2 months during summer 2013. Inclusion criteria for participants included being 18 years or older, speaking and reading English or Spanish, and being a patient of the clinic. The following patients were excluded: patients who were younger than 18 years and/or who did not speak and read English or Spanish. All of the survey materials, including a consent cover letter, a flyer, and a survey instrument, were available to participants in English and Spanish. A native Spanish speaker who is fluent in English translated English materials into Spanish as needed for the study. A native English speaker who is fluent in Spanish conducted the back-translation for the instrument. The investigators then verified the accuracy of the translation. Trained research assistants gave potential participants in the clinic waiting area a study flyer. Interested participants received a consent cover letter and a self-administered paper survey in their preferred language. A researcher was available to answer questions while participants completed the survey. The research team examined differences by country of origin (ie, US born and non-US born) and language (English speakers or Spanish speakers) because differences in birthplace, being US born or non-US born, and language have coincided with differences in physical and mental health statuses of free clinic patients.4 The participants were divided into three groups for analysis—US-born English speakers, non-US-born English speakers, and Spanish speakers—because the results of a previous study at a free clinic showed that these three groups are different from one another in health status and sociodemographic characteristics.4 All Spanish-speaking participants were non–US born. Well-validated and relatively brief screening tools were selected because participants had limited time to complete the survey. Measures Depression Depression during the past 2 weeks was assessed using the 5-item World Health Organization Well-Being Index (WHO-5).20 WHO-5 uses a 6-point Likert scale (5 = all of the time, 0 = none of the time) and has been shown to be highly sensitive and valid as a depression measure.20 The scores range from 0 to 25. A higher score refers to better mental health well-being. A score below 13 is a possible indication for depression diagnosed using the International Classification of Diseases-10. The WHO-5 showed high sensitivity with clinical diagnosis in primary care.21 Somatic Symptoms The Patient Health Questionnaire (PHQ)-15 is a valid, 15-item measure of somatic symptoms experienced in the past 4 weeks using a 3-point Likert scale response format (0 = not bothered at all, 1 = bothered a little, 2 = bothered a lot).22 Examples of somatic complaints represented include stomach pain, back pain, and headaches. PHQ-15 scores are defined as no somatic disorder, 1–4; mild somatization disorder, 5–9; moderate somatization disorder, 10–14; and severe somatization disorder 15 +. Neighborhood Environment and Sociodemographic Characteristics The study used two subscales from the Neighborhood Environment Walkability Scale, namely “safety from crime” and “neighborhood satisfaction.”23 The safety from crime subscale contains six questions (eg, “My neighborhood streets are well lit at night”) with a 4-point Likert scale (1 = strongly disagree, 4 = strongly agree). Three of the items are reverse-coded items. The neighborhood satisfaction subscale has 17 items (eg, “Are you satisfied with how easy and pleasant it is to walk in your neighborhood?”) with a 5-point Likert scale (1 = strongly dissatisfied, 5 = strongly satisfied). The scoring system is a mean of the items for each subscale. The Neighborhood Environment Walkability Scale has been validated24 and used in multiple countries.25 Demographic information included age, sex, race/ethnicity, education level, employment status, marital status, and country of origin. Data Analysis Data were analyzed using SPSS version 19 (IBM SPSS, Armonk, NY). Descriptive statistics were used to outline the distribution of the outcome and independent variables. Descriptive data were presented as means with standard deviations (SDs) for continuous variables, and frequencies and percentages for categorical variables. The participants were classified into three groups: US born who chose the English version of the survey (considered English speakers), non-US born who chose the English version of the survey (also considered English speakers), and non-US born who chose the Spanish version of the survey (considered Spanish speakers). The three groups were compared using Pearson χ2 for categorical variables and analysis of variance for continuous variables. Multiple regression analysis was conducted to test the association among depression, sociodemographic characteristics (age, female sex, high school diploma or higher, currently employed, and married), somatic symptoms, perceived neighborhood safety, perceived neighborhood satisfaction, and reference groups (non–US-born English speakers and non–US- born Spanish speakers). Regression coefficients (standard errors) were used to obtain a 95% confidence interval. Results Sociodemographic Information Table 1 presents the sociodemographic characteristics of the 346 participants. Overall, 99 US-born and 89 non–US-born participants chose the English version of the survey and 158 participants chose the Spanish version (all non-US born). The average age was 43.5 (SD 16.1) years and 65.9 % of the participants (n = 228) were women. There were no significant differences in age or sex among the three groups. Table 1 Participant sociodemographic characteristics More than half (66.7%) of the US-born English-speaking participants were white and nearly half (44.9 %) of the non–US-born English-speaking participants and the majority (94.3%) of the Spanish-speaking participants were Hispanic. A total of 87.9% of US-born English-speaking participants had a high school diploma or higher compared with 86.5% and 55.7% for non–US-born English speakers and Spanish speakers, respectively. The differences in race/ethnicity and the educational level among the three groups were statistically significant (P < 0.01). Almost 52% of Spanish speakers were employed versus only 39.4% of US-born English speakers; however, there were no statistically significant differences in employment status among the three groups. Although approximately half of the white and Hispanic participants were employed, less than 30% of Asian participants were employed. Almost half (45.4%) of the participants were married. There was a significant difference in marital status among the three groups (US-born English speakers 34.3%; non–US born-English speakers 51.7%; and non–US-born Spanish speakers 48.7%; P < 0.05). The 346 participants represented 32 countries, including Mexico (35.8% of participants) and the United States (28.6% of participants). After piloting the measure, the clinic staff and researchers concluded that convenience sampling would work best at this clinic because there was no way to accurately predict the patient population each day. As a result, this study had more female, Hispanic, and employed participants than the overall clinic patient population (54% women, 48% Hispanic, and 42% employed). Depression, Somatic Symptoms, Neighborhood Safety, and Neighborhood Satisfaction Table 2 presents depression, somatic symptoms, neighborhood safety, and neighborhood satisfaction by US-born English speakers, non–US-born English speakers, and Spanish speakers. The average WHO-5 score that measures mental health well-being and depression was 13.3 (SD 6.2). There was a significant difference in depression (P < 0.01) among the three groups. Specifically, US-born English speakers (11.6, SD 6.3) reported higher levels of depression than non–US-born Spanish speakers (13.6, SD 6.1) and non–US-born English speakers (14.7, SD 5.6; P < 0.01). Likewise, US-born English speakers (10.8, SD 5.7) reported a greater number of somatic symptoms than non–US-born Spanish speakers (9.0, SD 5.8) and non–US- born English speakers (8.8, SD 6.5; P < 0.05). There were no significant differences in perceived neighborhood safety and satisfaction across the three groups. Table 2 Depression, somatic symptoms, and perceived neighborhood environment Table 3 presents results of regression analysis to predict depression. A higher number of somatic symptoms were associated with a higher level of depression (P < 0.01). Higher level of education (P < 0.05) and higher level of perceived neighborhood satisfaction (P < 0.01) were related to lower levels of depression. Non–US-born English-speaking participants reported significantly lower levels of depression than US-born participants (P < 0.01). Table 3 Predictors of depression using regression analysis (N = 346) An additional analysis was conducted to examine differences in depressive symptoms among white, Asian, and Hispanic participants in the whole group; between white and Hispanic participants in the US-born English-speaking subgroup; and between Hispanic and Asian participants in the non–US-born English-speaking subgroup. There was a significant difference among the ethnic groups from lowest to highest depression levels: Asian, Hispanic, and white (P < 0.01). There was no significant difference in depression levels by ethnicity in the subgroups. Discussion This study examined depression, somatic symptoms, and perceived neighborhood environment among US-born and non–US-born free clinic patients and had three main findings. First, US-born English speakers reported higher levels of depression and more somatic symptoms than non–US-born English or Spanish speakers. Second, non–US-born English speakers reported lower levels of depression and fewer somatic symptoms than Spanish speakers. Third, somatic symptoms and perceived neighborhood satisfaction were related to depression. The findings that US-born free clinic patients reported poorer mental health than non–US-born free clinic patients were consistent with previous studies on free clinic patients.4,26 Nearly 70% of US-born English-speaking participants were white. The results may be related to race/ethnicity differences between US-born English speakers and non–US-born English or Spanish speakers. Previous studies show that white Americans had a higher prevalence of major depression than African Americans and Mexican Americans.7 White Americans also reported a higher prevalence of psychiatric disorders than Hispanics, Asian Americans, and African Americans.27 Racial and ethnic minority groups, however, tend to experience barriers related to mental health treatment access.28 There is a possibility that US-born English-speaking patients differ in social mobility or sociodemographics in ways that may be related to depression. Future studies should address what social factors such as immigration status or employment would contribute to the variation in depression by ethnicity. Among non–US-born participants, English speakers reported lower levels of depression and fewer somatic symptoms than Spanish speakers. The differences in depression between non–US-born English speakers and Spanish speakers may be related to language barriers or race/ethnicity. Spanish speakers may have more language barriers than English speakers when they seek healthcare services. Non–US-born English speakers included a higher percentage of Asians than Hispanics compared with non–US-born Spanish speakers. Asian Americans have a lower lifetime prevalence of psychiatric disorders than Hispanics.27 Future research should further examine factors influencing the differences in mental health between non–US-born English speaking and Spanish-speaking free clinic patients. The results of this study suggest that somatic symptoms are associated with depression. The results are consistent with previous studies in general primary care settings29 and indicate that findings from studies in general primary care settings can be applicable to patients who attend free clinics. Although approximately 10% of primary care patients may have depression, the treatment rate is still low in primary care11; however, there may be a large number of hidden cases of depression in primary care.30 Primary care practitioners can assess and manage mental as well as physical health, although the rate of actual implementations remains low.31 Providing mental health services to patients in a free clinic setting is needed; however, because of limited financial and human resources,2,32 free clinics cannot meet all of the needs directly, including mental health services. The cost for free clinics to provide access to mental health professionals often is prohibitive. Training general practitioners in the treatment of patients with somatic symptoms is effective to improve physical functioning33 and may be feasible to implement at a free clinic. Furthermore, a collaborative practice model in which a primary care free clinic partners with a volunteer-run mental health clinic34 and models of collaborative mental and primary health care may be applicable for free clinics by working with other organizations and public health programs.35,36 The health outcome of the model is still unknown, however. Although there is a free mental health clinic in the same catchment area of the free clinic where this study was performed, there is no specific evidence-based program that could be implemented to help prevent patients from needing such extensive mental health services. Future studies should examine which patients are referred to specialist services and why and how might that affect the care model in free clinics compared with other kinds of primary care services. Studies should include collaborative pilot programs and evaluation of health outcomes. In addition to somatic symptoms, neighborhood satisfaction was related to depression. Paradoxically, another study suggests well-being influenced by neighborhood environments is mediated through social contact or social capital but not through satisfaction with neighborhood environment.37 Given that free clinic patients are socioeconomically disadvantaged and may experience neighborhood stressors such as violence or noise, neighborhood satisfaction may be an essential factor in the mental health of these patients. As such, health-promotion programs at the community level, not only at the clinic level, would be valuable in improving the mental health of free clinic patients because neighborhood characteristics affect stress and health and can foster health-promotion policies.38 There were some limitations to our study. This study was cross-sectional and could not examine causal relations. Future research should incorporate a longitudinal design to identify causal relations among depression, somatic symptoms, and the neighborhood environment. The non–US-born participants were diverse; they represented 32 different countries. Unfortunately, the number of patients was not high enough to break down into groups by country or region to examine differences. In addition, because the data were collected at one free clinic, generalizability to all free clinics across the United States is limited. Conclusions A recognition of the mental health needs of free clinic patients is much needed; however, providing comprehensive mental health services in a free clinic setting often is difficult. Health-promotion programs at the community level would be valuable in improving the mental health of free clinic patients. Although free clinics have provided primary care to underserved populations for more than 40 years, there are few generalizable systematic studies on free clinics.32 The actual health outcomes of free clinic services are not well known. The present study added more detailed information about free clinic patients, including new insights about depression, somatic symptoms, and perceived neighborhood environment by comparing US-born and non–US-born patients and language (English or Spanish), which few previous studies have examined.
Key Points What began as a response to both foreign terrorism and domestic bioterrorism attacks evolved into an all-hazards medical disaster solution. Although this is only one state’s experience, each US state has developed medical disaster response capabilities during the past 13 years. Each US state chose a path that was influenced by federal benchmarks and standards associated with the funding received. This review serves as a catalyst to ask questions and learn more about where states are in developing medical disaster response systems through the Hospital Preparedness Program. The September 11, 2001 (9/11) terrorist attacks and the ensuing distribution of anthrax-laced letters across many states revealed substantial gaps in medical decontamination and mass casualty response for organizations that evaluated the disasters in the context of their own capabilities. In the aftermath of the disasters, the frank realization by subject matter experts was that no existing local, state, or federal agency could have optimally managed the disaster nor were they prepared for additional attacks on a similar scale. In the months that followed the attacks, uncertainty prevailed and the concern about ongoing acts of terrorism and bioterrorism was omnipresent across the country. Time was critical. Guidance and funding were quickly joined to lead a comprehensive build-up of civilian medical resources for disaster response in each state.1,2 From public health to hospital preparedness, medical disaster response capacity in every state, including North Carolina, developed over multiple fronts.3–6 The initial focus following 9/11 was terrorism and bioterrorism7; however, the focus has broadened to include emerging threats such as pandemic disease outbreaks8–10 and returned to include traditional threats such as hurricanes and tornadoes.11 This article reviews the genesis of the North Carolina disaster preparedness/response program, offers examples of how it has been used, examines what the future holds regarding sustained investment and ongoing development, and offers insights for individuals interested in developing and benchmarking their own programs. State Medical Response System and Bioterrorism Hospital Preparedness Program Post-9/11 The federal effort became known as the Bioterrorism Hospital Preparedness Program (BTHPP), later shortened to HPP.2 Between 2002 and 2005, more than $1 billion was spent nationwide on hospital preparedness, provided states met BTHPP benchmarks, relying largely on data, experience, and expert opinion.12–16 For North Carolina, the Trauma Regional Advisory Councils, which work routinely with hospitals, emergency medical services (EMS), and public health, were considered the best locations to coordinate local and regional medical disaster response.17 Simply adding a medical disaster component to this well-established system of coalitions facilitated rapid program development. The agencies that came together to create this system included the Division of Emergency Management, the Division of Public Health, the Office of Emergency Medical Services, and the Special Operations Response Team. These agencies known at the local, state, and federal levels of government as Emergency Support Function-8, signed a memorandum of agreement on January 28, 2002, identifying principal response components to improve medical disaster response.18 By leveraging the expertise of these agencies, a disaster healthcare–focused state medical response system (SMRS) was created. The first concept of operations included hospital and EMS-based teams that could provide decontamination and mass casualty medical care during a disaster. State Medical Assistance Teams The State Medical Assistance Teams (SMATs) were configured in tiers of response capability. These tiers were identified as SMATs I, II, and IIIs, with level I teams having the greatest resources (Table 1). The system as designed included a single level I SMAT, which included a field hospital component. The Trauma Regional Advisory Councils–based level II SMATs served as lead agencies for the regions. Level III SMATs were based at EMS agencies around the state. Critical benchmarks for the grant recipients at that time included such components as identifying alternate care facilities for each hospital, developing surge capacity, and developing regional disaster plans.19 The SMATs served as the cornerstone of the SMRS in the early days. Table 1 Initial types of SMATs, original purpose, and evolution Development of the SMAT program included several distinct periods. The marker separating the first from the second evolution of the program is distinguished by that which predated and played a key role in the response to Hurricane Katrina. After Hurricane Katrina decimated the Gulf Coast of Mississippi in 2005, Mississippi state officials requested that North Carolina provide a mobile field hospital through a mutual aid agreement that exists between states.20 A prototype field hospital based at a Charlotte, North Carolina–area hospital,21,22 augmented with staffing from the various SMATs, was mobilized. Shortly after the hurricane cleared the area, the NCSMAT field hospital (Fig. 1) responded to and became operational in Waveland, Mississippi. Fig. 1 First full-scale deployment of the North Carolina State Medical Response Service, relying on teams and equipment from the State Medical Assistance Teams and a team and equipment from a Charlotte-area hospital. 1, Helicopter pad; 2, pharmacy; 3, command; 4, crew quarters; 5, supply/logistics; 6, patient care area; 7, refrigerated storage; 8, computed tomography scanner; 9, shower trailer; 10, satellite communications. For the next 7 weeks, this facility, a collection of tents, trailers, and equipment, staffed with physicians, nurses, paramedics, and other support personnel, served thousands of patients. More than 7500 patients were seen in the field hospital, another approximately 7000 received some form of vaccination or inoculation before that function was transitioned to Mississippi Public Health, and an additional 7000 received a replacement prescription until local providers reopened their offices for routine visits.21,23 During the 7 weeks of service, various members of the media, Mississippi Governor Haley Barbour, former President George H.W. Bush, and countless others, visited the NCSMAT field hospital. Serving more than 20,000 patients, this hospital would later be described in a Congressional Report as “an invaluable asset to Mississippi’s most hard hit area in Hancock County.”22,24 Before Hurricane Katrina, the teams had trained and exercised extensively, with much of the original aim being medical decontamination following a bioterrorism attack. Although those skills were not critical to the Hurricane Katrina response, merely having the teams, trailers, organizations, and equipment proved vital in the hours and days following the disaster. The key lesson learned was the need to evolve into all-hazards disaster response teams. State Medical Asset Resource Tracking Tool One of the lessons learned in the aftermath of the 9/11 attacks was the need for states to have a more up-to-date and dynamic tracking system for hospital beds and ambulances. Nationally, this need led to the creation of the Hospital Available Beds for Emergencies and Disasters system. On a state level, the State Medical Asset Resource Tracking Tool, a Web-based computer program, was created to regularly monitor hospital, EMS, and health center resources.25 Through this program, hospital information is updated daily to reflect the availability of hospital beds, specialty service capability, and disaster resources. Health centers provide information on a weekly basis that identifies clinical services offered, laboratory capabilities, and any inpatient bed capacity. EMS systems update information weekly, which includes personnel and vehicle availability and disaster resource capabilities. The state data are uploaded daily to the national system. Emergency System for Advance Registration of Volunteer Health Professionals Following 9/11, a surge of volunteers stepped forward to help, but there was no system to coordinate their services or validate their claims of credentials. In 2002, the US Congress authorized the creation of a national registry of volunteers who could be validated for a current medical credential called the Emergency System for Advance Registration of Volunteer Health Professionals (ESAR-VHP).26 Each state established its own registry to work with ESAR-VHP by collecting information locally and reporting it periodically to the federal system. This system became the means by which personnel lists were maintained that are cross-referenced to the various state agencies responsible for validating credentials. This system also serves as the means of communications to alert and notify disaster response personnel of a potential mission. Communications One of the key findings in the 9/11 Commission Report27 included the inability of emergency responders in New York City to communicate directly with each other or access back-up systems when their primary antenna sites were destroyed. An important aspect of the SMRS was to expand the communications systems for emergency responders relying on the statewide 800-MHz system. Additional investments included expansion and system improvement for the existing UHF-band Med Radio system, which placed radios with each of the hospitals, connecting them across the state. This redundant approach improved communications reliability, allowing all involved in both day-to-day and disaster response to communicate more easily and reliably. Medical Reserve Corps The Medical Reserve Corps (MRC) was created by President George W. Bush in 2002 to allow self-organizing groups a structure with limited immunity to volunteer their services in a disaster. The MRC serves in a variety of roles that range from manpower for disaster response to a mass influenza inoculation program for a local health department. Each of the SMAT IIs works with one or more MRC in its region. The MRC provides additional volunteer medical staff. A radiological emergency response team also was established through a partnership with the MRC and the Radiological Emergency Volunteer Corps. North Carolina Burn Surge Program One of the BTHPP benchmarks included a focus on specialty bed resources. The most scarce critical resources following a terrorist attack include those associated with caring for burn, pediatric, and trauma patients.13 Of these critical resources, managing a surge of burn patients was considered the least understood and offered the greatest opportunity to close a gap in preparedness following a terrorist attack. In the past 25 years, North Carolina has responded to several incidents involving mass burn casualties, including the nation’s second deadliest industrial plant fire,28 the Fort Bragg/Pope Air Force Base fighter jet and cargo plane collision,29,30 a passenger jet crash in Charlotte,31 and a pharmaceutical plant explosion.32 Subsequently, the state’s two burn centers worked together to develop burn surge resources and the burn surge program as an SMRS component.33,34 In addition to exercises, two subsequent disasters have been managed relying on the burn disaster program, with excellent results. These disasters included an industrial plant explosion near Raleigh35,36 and as a reception point for receiving burn-injured patients from the 2010 earthquake in Haiti.37,38 National Mobile Disaster Hospital The National Mobile Disaster Hospital project began in 2005 with the Department of Homeland Security’s catastrophic care initiative; however, by 2006, funding and the project were halted. In 2009, the Department of Homeland Security assigned the National Mobile Disaster Hospital to North Carolina to be completed, maintained, and available for nationwide response. The National Mobile Disaster Hospital allows a flexible response through its scalable and modular design. The purpose of the hospital is to provide hospital care capability during an emergency response by augmenting or temporarily replacing a hospital. When deployed, the hospital functions under the direction of the requesting host medical unit. The hospital deploys with a coordination team to include logistic support and clinical and technical advisors. Upon request, medical personnel may be provided by either the region and/or the state of North Carolina. The hospital has many of the capabilities found in a typical community hospital (Table 2). Table 2 Basic overview of the MDH and its deployable components Disaster Medical Specialist The Disaster Medical Specialist (DMS) educational program developed out of a request for specialty medical training pertaining to entrapped patients in collapsed structures. In 2005, remnants of hurricanes Frances and Ivan brought 9 days of rain to western North Carolina. The ensuing floods destroyed hundreds of homes, leaving dozens of residents trapped, injured, or killed. Mutual aid responders from the Charlotte Fire Department Urban Search and Rescue team encountered several unusual medical rescue scenarios. An after-action report identified the need for urban search and rescue medical training, which could be used in multiple facets of disaster response. The DMS educational program has been conducted annually or biannually since 2006. Approximately 350 paramedics, nurses, and physicians, representing 46 emergency response agencies, have completed the DMS program. Participants have played integral roles in full-scale exercises and actual disasters since the program began. Ambulance Strike Teams and Ambulance Buses Ambulance strike teams39–41 were added to the SMRS for the purpose of creating a cadre of resources that can respond in the immediate aftermath of a disaster in a self-sustaining manner.42 The ambulance strike teams typically include five ambulances and one support vehicle (trailer) for spare parts, materials, and supplies. The eight teams are located in seven regions, including a large local provider (Fig. 2) and have been used for a variety of disasters, from hurricanes to wildfires. Fig. 2 Ambulance strike teams are positioned around North Carolina and rely on either local regions or regional agencies for providing key components for the teams. 1, Mountain Area Trauma Regional Advisory Committee, Asheville; 2, Triad Regional Advisory Council, Winston-Salem; 3, MidCarolina Regional Advisory Council, Chapel Hill; 4, CapRAC (Regional Advisory Council), Raleigh; 5, Johnston Ambulance Service; 6, Eastern Regional Advisory Council, Greenville; 7, Metrolina Regional Advisory Council, Charlotte; 8, South Eastern Regional Advisory Council, Wilmington. In addition to the five traditional ambulances, the ambulance strike teams may include one or more ambulance buses (AmBuses) if needed. The AmBuses have gained significant acceptance across the country43,44 and can transport more than a dozen patients. There are 12 AmBuses stationed statewide (Fig. 3). Their configuration generally includes a stretcher area for 7 critically injured patients and as many as 14 additional stretcher patients, for a total of 21 patients (Fig. 4). AmBuses are used routinely for a variety of missions, including firefighter rehabilitation at the scene of a structure fire and routine response to multiple-patient vehicle accidents. Fig. 3 Ambulance buses are positioned around North Carolina and rely on local regions, regional agencies, or local agencies for maintaining and responding them. 1, Buncombe emergency medical services, Asheville; 2, Forsyth County emergency medical services, Winston-Salem; 3, Guilford County emergency medical services, Greensboro; 4, Wake emergency medical services, Raleigh; 5, Eastern Regional Advisory Council Greenville; 6, Medic Charlotte (2 ambulance buses); 7, Fort Bragg emergency medical services, Fayetteville; 8, Brunswick emergency medical services, Shalotte; 9, New Hanover Regional emergency medical services, Wilmington; 10, Morehead City Fire and Rescue; 11, Currituck Fire and Rescue. Fig. 4 Example of ambulance buses in service and in use across North Carolina. Most recently built ambulance buses share similarities in design and capacity. Mobile Pharmacy Units In the early days of the SMRS, preparation for a bioterrorism attack included the purchase and maintenance of antibiotics and other medications in significant quantities; therefore it was essential to involve pharmacists. During the response to Hurricane Katrina, pharmacists were vital. Their principal role was to assist patients with day-to-day medications such as insulin, tetanus toxoid, and blood pressure medication. There are two mobile pharmacy units that can deploy with the SMATs. These units are closely affiliated with major hospitals to ensure their stock is rotated and shelf life preserved. The layout of the pharmacies was influenced by a makeshift pharmacy trailer that was created during the response to the Hurricane Katrina disaster. Volunteer Organizations Active in Disaster Volunteer Organizations Active in Disaster has been active in disaster response for more than 40 years.45 For local activities, these volunteer organizations offer an opportunity to leverage local support for community events, keeping everyone engaged. The volunteer component has allowed the SMATs to participate in multiple planned mass gathering events. These events include such activities as college football games, concerts, marathons, air shows, and community festivals. The Volunteer Organizations Active in Disaster include the Methodist Men, the American Radio Relay League, the American Red Cross, Catholic Charities, and Habitat for Humanity. These organizations offer a pool of committed and energetic manpower. The North Carolina Baptist Men are an example, providing manpower and technical support for the National Mobile Disaster Hospital. Discussion Across North Carolina, dozens of tabletop, functional, and full-scale exercises have been conducted since the creation of the SMRS. Team responses to and participation in small-scale disasters and planned events are essential to maintain interest and to keep the training current. Lessons learned from these activities have been applied to improve operational efficiency and effectiveness. Two of the more notable deployments used as an exercise but coincided with large mass-gathering events. These events include the 2006 Tall Ships, with hundreds of national and international ships and their crews sailing into port at Beaufort, North Carolina for a week of activities, and the 2012 Democratic National Convention (Fig. 5), which also resulted in a large-scale deployment. Both events attracted hundreds of thousands of people to the areas in which they were held. Fig. 5 First deployment of the Mobile Disaster Hospital connected with State Medical Assistance Teams equipment from several Regional Advisory Councils at the Democratic National Convention held in Charlotte, North Carolina in 2012. 1, Crew quarters and meeting and meal areas; 2, Disaster Medical Assistance Team crew buses; 3, one of several generators; 4, crew quarters shelter vendor support; 5, command; 6, emergency department and triage; 7, one of multiple patient care areas; 8, surgical processing area; 9, State Medical Assistance Teams crew quarters, communications, and observation deck; 10, mobile operating rooms; 11, decontamination tent. SMRS teams also have responded to large-scale actual disasters, including the Kentucky ice storms of 2009 and Hurricane Irene. Smaller disasters included nursing facility evacuations, wildfires, tornadoes, or simply providing temporary shelter for one jurisdiction that lost its local health department to flooding. Lessons learned from exercises and real-world disasters point to the two distinct keys to success: flexibility and scalability. The SMRS evolution has included significant changes through the years, embracing the all-hazards approach and adjusting to the ever-changing landscape involving local hospital systems and EMS agencies. It is not financially feasible to train using the sheer numbers needed for large-scale deployment; therefore, volunteers are essential team members. Unfortunately, volunteers have multiple commitments, and as such, the larger the deployment, the more time is needed to muster the human resources. Long-term financial sustainability remains a concern for the states that created these mobile hospital resources. California purchased $176 million worth of mobile hospitals in 2006; however, by 2012, the state was considering “selling off the parts on eBay” and storing the larger components because they lacked sustaining funds.46 The most substantial national effort to prepare for a medical disaster during the past 50 years was addressed in the 1960s by the Civil Defense Emergency Hospital (CDEH) program, which placed 1928 200-bed field hospitals across the nation.47,48 Each CDEH included stretchers, oxygen, an operating room, a pharmacy, x-ray equipment, and sufficient supplies to operate for 30 days.48–51 Although 35 CDEHs were once located in North Carolina, as the years passed and federal funding ended, they were abandoned or scavenged for use by local hospitals and EMS agencies across the United States. Thus far, North Carolina has successfully sustained the financial health of the SMRS program by leveraging federal funding with in-kind contributions from local healthcare systems and EMS agencies. Leadership is provided locally by lead hospitals and EMS agencies, with overall management provided statewide by the North Carolina Office of EMS. In-kind contributions have ranged from biomedical support to rotating supplies and pharmaceutical stock and several volunteer organizations have provided substantial manpower. The ongoing financial health of the SMRS requires dedicated funding that will survive the eventual end of federal funding. This system was created to support, augment, and temporarily replace components of the local healthcare system. As such, there may be an opportunity to create an appropriation line item for the state government to provide baseline funding and include a means of billing for services when these agencies are deployed. Regardless, a solution needs to be in place before federal funding ends. Conclusions The SMRS represents groups, organizations, and partnerships that work in a complementary fashion to manage medical disasters. Although the SMATs remain a key system component, the most important aspect is the regional systems, organization of teams, training, and an ongoing focus on medical disaster response. When the program began, SMRS relied largely on the existing trauma Regional Advisory Councils as a starting point. Although not a perfect fit for everyone, the councils were a good place to start. This has evolved into a series of regional disaster preparedness coalitions, with stakeholders representing all involved from the hospitals, the EMS agencies, community health centers, fire departments, emergency management, Volunteer Organizations Active in Disaster, and public health. For those focused on Emergency Support Function-8 activities, the SMRS has emerged as a successful example of how local, state, and federal efforts can be coordinated for functionality and leveraged reliance on the strengths of each to respond when disaster strikes.
Key Points Hunting-related injuries, in particular, falls from hunting stands, are increasingly common and are an underreported cause of orthopedic injury. Although initiatives have reduced the incidence of firearms-related injury, hunting stands remain common causes of severe injury for hunters. Increased awareness of the mechanism and spectrum of injury due to falls from hunting stands could lead to reduced incidence and morbidity associated with these accidents. Hunting is an extremely popular recreational activity, with more than 14 million people obtaining hunting licenses annually in the United States.1 As the activity gains popularity, the number of injuries related to its practice, mainly from falls from hunting platforms and accidental firearms discharges, are increasing. Injury rates have increased from 0.59 injuries per 100,000 deer hunters in 1987 to 7.08 in 2006.2 During the past few decades, several initiatives have been proposed to decrease hunting-related injuries, but most of these have focused on firearms-related injuries. States have instituted formal requirements for the completion of hunter safety courses and possession of valid licenses before hunting. Another initiative is encouraging the wearing of “hunters’ orange,” which has been shown to decrease firearms-related hunting injuries. Despite these measures, injuries have been increasing. It has been suggested that the hunting stand, as opposed to firearms, is the principal cause of the majority of hunting-related injuries3; indeed, data suggest that fewer than 2% of nonfatal firearms-related injuries are related to recreation.4 Hunting Stand Injuries In a 1993 survey, 9.5 of 11 million hunters used hunting stands, and of those, 2.5 million reported falling out of their stands, resulting in 105,000 injuries.2 Hunting stand injuries accounted for 36% of hunting injuries in Georgia during a 10-year period,5 or 9 hunting stand–related injuries per 100,000 hunting licenses sold per year.3 In fact, falls from trees or tree stands are the most common hunting-related injury requiring hospital admission and often result in severe injuries, according to several studies.6–8 In 1989, hunting stand–related falls were the leading cause of hunting deaths in the United States.9 Up to 8% of reported hunting stand injuries are fatal and account for 20% of all hunting-related fatalities.5,9 A review of deer stand–related injuries in West Virginia found a higher fatality rate associated with tree stand falls than firearms injuries.6 An understanding of these injuries requires a basic knowledge of the typical equipment involved. A hunting stand is an elevated platform that is used commonly for big game hunting (Figs. 1 and 2). These stands increase visibility and decrease ground scent,6 giving the hunter an advantage. Commercially available hunting stands often consist of a small platform approximately 2 ft × 2 ft1 or a small seat attached to a tree with straps or bolts.9 The optimum height for hunting purposes is 15 to 25 ft off the ground, an altitude that would, should a hunter fall from the stand, result in a terminal velocity of 30 mph.6 Most commercially available hunting stands adhere to guidelines in an effort to minimize the risk of falls; however, in one study, 66% of hunters used homemade hunting stands.6 These homemade stands certainly vary greatly in construction and safety profile and may place hunters at greater risk of injury. Fig. 1 Examples of elevated hunting stands. There are a variety of commercially available models, but most stands are about 2 × 2 ft in area and can be attached to a tree by either straps (Fig. 1) or bolts (Fig. 2). For hunting purposes, these stands are usually 15 to 25 ft above ground level, a height that can predispose the hunter to serious injury in the event of a fall. Fig. 2 Epidemiology Hunting stand–related injuries frequently occur during big game season, with up to 70% of injuries occurring during October and November.6 Most often, they occur on the beginning of the weekend, with 30% of falls taking place on Saturday.2 Those injured are typically men (90%–96%)2,3 in their late 30s.5,6 The average fall has been reported to be between 17.56 and 18 ft.2 Not surprisingly, in one study, those who died averaged a fall of 24 ft, whereas survivors fell an average of 17 ft.2 Mechanism of Injury Various factors lead to tree stand injuries. Metz et al identified the following factors: structural failure (25%), hunter entering or exiting the stand (20%), alcohol (17%), hunter falling asleep (10%), and rifle recoil (7%).9 Another study reported mechanical failure of the stand as a frequent cause leading to falls, accounting for 32% of injuries, whereas a hunter falling asleep accounted for 5%, and intoxication 4%.5 Interestingly, alcohol has been reported to be involved in cases anywhere from fewer than 2% to more than 20% of the time.2,3,9,10 Risk factors associated with falls include hunting without adult supervision, not completing a hunter safety course, and a faulty or homemade stand.2,3,5,9,10 Spectrum of Injury Hunting stand falls can be associated with significant injury severity, with a mean Injury Severity Score documented to range from 9.2 to 13.2,6 As such, care of the patient who has sustained a fall from a hunting stand requires a careful evaluation for both orthopedic and nonorthopedic injuries. Hunting stand–related injuries frequently cause fractures. Spine, pelvis, and extremity fractures are all well documented, with one study reporting that of 214 fallen hunters, 160 (73%) sustained a fracture.3 A review of hunting stand–related injuries reported that of 30 patients admitted to a trauma center, 21 (70%) required surgery, 15 (50%) for orthopedic injuries.11 Thoracic and lumbar spine fractures are particularly common, occurring in up to 52% of patients requiring treatment.4,5 Up to one-third (37%) of spine fractures involved the cervical spine. Associated spinal cord injury is common, occurring in 10 of 13 patients and 5 of 8 patients in limited case series.1 Halanski and Corden found that up to 10% of falling hunters sustain permanent neurologic dysfunction.8 A large series documented that 4% of all patients sustained a pelvic fracture,9 and studies have shown that 40% to 47% of all patients experience a fracture to an extremity.4,5 Multiple concomitant injuries are common: 10% of hunters with spinal injury had pelvic fracture, and 24% of those with a spinal injury had an extremity fracture.1 The most common extremity fractures included those to the tibia and fibula (10%), radius and ulna (8%), foot and ankle (8%), and humerus (2%).9 Nonorthopedic injuries include closed head injury, lung injuries, and solid organ injury. Head injuries have been documented in 18% to 24% of cases.3,5,9 Injuries to the lungs and ribs have been shown to occur frequently as well (8%–16%), but these are even more common in patients with spinal injuries. A total of 19% of patients with a spinal injury had rib fractures and 14% had pneumothoraces.1 Injury to solid organs also can occur as a result of the shear force and shockwave associated with a fall from a height and are documented in 6% to 12% of cases.3,9 The kidney is particularly susceptible to these deceleration forces.6,12 Other mechanisms of injury associated with hunting stands have been documented, including asphyxiation caused by improperly fitted and manufactured safety belts/harnesses.7 A 2008 Consumer Product Safety Commission alert emphasized the importance of a “full-body strap” as opposed to a simple waist belt to prevent this mode of injury13 (Figs. 3–6). Fig. 3 An example of a full-body harness (Figs. 3 and 4) and a shoulder harness (Figs. 5 and 6). Shoulder harnesses have been shown to be inadequate when used for an elevated hunting stand because they have been associated with asphyxiation after a fall event. Full body harnesses incorporate the lower extremities into the harness and are the recommended safety device for use on an elevated hunting stand.13,14 Fig. 4 Fig. 5 Fig. 6 Economic Impact Estimating the true burden of disease of secondary hunting-related injuries is difficult because many hunting-related injuries are not reported.5 In fact, in one study, less than one-fourth (22%) of hunters who fell from a hunting stand actually sought medical care.2 Although many states require reporting firearms discharges resulting in injury, reporting of injuries related to falls or other hunting-related injuries is not required.11 Nevertheless, several studies have attempted to detail the burden of injury experienced by the victims of hunting stand–related injuries. Smith et al reported that 52% of patients who presented to an emergency department after a fall from a hunting stand required hospital admission, with 11% requiring observation and 10% requiring surgical intervention secondary to injuries sustained.2 Twenty-five percent actually required admission to an intensive care unit during their stay. Ultimately, 23% of patients had at least one impairment at discharge, most frequently involving walking or transferring. In general, the average length of the hospital stay for patients who require hospital admission ranges from 3 to 6 days2,4,5 but can be up to 14 days in patients who sustain spinal cord injuries.1 In one account specifically analyzing spinal injuries in hunters, 13 of 22 patients sustained injuries that required operative stabilization.1 Other studies have corroborated that hunters who sustain injuries frequently require surgery.3,11 Crockett et al reported that more than 80% of their patients required operative fixation, with more than 11% eventually requiring disposition to a nursing or rehabilitation facility.3 Injury Prevention Strategies Hunting is a common recreational activity for many Americans, and many hunters frequently use hunting stands.2 Because up to one-fourth of hunters report falling out of their hunting stands,2 the importance of educating hunters cannot be understated. They should be instructed regarding the risks of and potential for falls from hunting stands, as well as their proper construction, use of safety harnesses, standardized inspection of stands and harnesses, and risks of hunting alone.5,7,13 Commercially developed hunting stands should be held to certain mandates such as yearly inspections to ensure proper installation, ability to maintain the weight of the hunter, and the use of full-body harnesses, as opposed to waist belts or shoulder harnesses, which have been associated with asphyxiation after falls.13,14 Because the majority of hunting stand injuries are associated with errors in judgment or improper preparation, public awareness campaigns could significantly reduce tree stand injuries. Mandated reporting of firearms accidents and numerous other interventions have successfully decreased the incidence of firearms-related injury. Hunting stand fall–related injuries could similarly benefit from a heightened degree of attention.6
Key Points Children with autism and autism spectrum disorders were compared against clinical controls to determine the effectiveness and safety of intravenous dexmedetomidine for deep sedation. This study was a quality assurance data review of children who underwent procedural sedation with dexmedetomidine for magnetic resonance imaging scans. Our intensivist-based procedural sedation program adheres to policies and guidelines based on the Joint Commission and the American Academy of Pediatrics’ recommendations. Children with autism or autistic spectrum disorders can be sedated successfully for magnetic resonance imaging with intravenous dexmedetomidine without complications. Autism spectrum disorders (ASD) are a group of developmental disabilities characterized by impairments in social interaction and communication and by restricted, repetitive, and stereotyped patterns of behavior.1 In addition, up to 30% of children with ASD also have comorbid intellectual disability (IQ <70).2 As a result of the difficulty they experience adjusting to changes in routine and the environment, children with autism have been described as difficult to sedate, which creates a challenge in obtaining diagnostic studies that require the child to be motionless.3,4 The ideal agent for these procedures remains elusive. Benzodiazepines may be effective in older children who have only mild procedure-related anxiety, but may not provide a sufficient depth of sedation in other children with greater levels of disability.5 Because its ease of administration, safety profile, and limited effects on the electroencephalogram, chloral hydrate remains a popular choice, but it is associated with an unpredictable onset and duration of action and moderate failure rate, particularly in children who are older and/or who have underlying neurologic disorders.6–8 It has been reported that the use of barbiturates, most commonly pentobarbital or methohexital, also may be associated with sedation failure, prolonged sedation, respiratory depression, hypotension, and recovery-related agitation.9–11 Because of its rapid recovery time, propofol has become a popular agent; however, it too may be associated with respiratory depression and hypotension.12 The use of propofol in some institutions or jurisdictions is restricted to anesthesiologists, limiting its availability. Dexmedetomidine is a relatively new, α2-adrenergic receptor agonist with both sedative and analgesic properties. It has a distribution half-life of 6 minutes and an elimination half-life of 2 hours.13 Its success as a sedative agent varies depending on the dose and clinical situation.14 Five prospective trials have evaluated the efficacy of dexmedetomidine for sedation during noninvasive radiologic imaging.5,15–18 Dexmedetomidine can be associated with adverse effects of hypotension, bradycardia, and transient hypertension with the loading dose. We have used this medicine at our institution for the past 5 years for magnetic resonance imaging (MRI) and other noninvasive radiologic procedures. The goal of this retrospective study was to present our institutional experience with dexmedetomidine in relation to safety, efficacy, related adverse effects, and sedation parameters in children with and without ASD. Methods This study, approved by our institutional review board, is a quality assurance data review of children who underwent procedural sedation with dexmedetomidine for MRI scans between July 2007 and December 2012 at Riley Hospital for Children, Indiana University Health North Campus. Charts were reviewed for 56 children with autism or an ASD (including Asperger, pervasive developmental disorder, and pervasive developmental disorder-not otherwise specified) and 107 children without such diagnoses. All of the patients in the A/ASD group had the primary diagnosis of A/ASD as established by their neurologist and was provided on the request form by the physician making the referral for MRI. Data included patient demographics, underlying and acute diagnosis, occurrence of adverse events, physiologic variables, drug dosages and procedure, sedation, and recovery times. The average (standard deviation) age in years of patients with autism was 6.1 (0.3) years and the average age of patients in the control group was 5 (0.2) years. Average weights, respectively, were 21.77 kg (1.1) and 21.59 kg (0.7). Our facility has an intensivist-based procedural sedation program that adheres to policies and guidelines based on recommendations by the Joint Commission and the American Academy of Pediatrics.19,20 Patients are prescreened via telephone interview by a sedation nurse with a parent/guardian present during the interview or via a review of the chart filled out by the primary physician. Study inclusion and exclusion criteria are shown in Table 1. The sedation nurses and intensivists also assess patients at the time of the sedation. Table 1 Inclusion and exclusion criteria A successful periprocedure process is standard for all of the children receiving MRI sedation, including providing telephonic family education before the procedure date, establishing a quiet room near the MRI suite, establishing minimal separation from the attachment figure such as the mother, using distraction techniques such as electronic tablet games and music for placement of intravenous (IV) and monitoring leads, as well as providing the option for oral or intranasal medication after discussion with the family. Our sedation team used a standard approach to dexmedetomidine procedural sedation using an IV bolus of 2 μg/kg administered for 10 minutes, followed by a maintenance infusion of 1 μg · kg−1 · hour−1. A second bolus of 2 μg/kg of dexmedetomidine was administered immediately to patients who were not adequately sedated before initiating the maintenance infusion. Additional IV boluses of medication, such as midazolam, also were used individually when necessary per physician discretion. Premedication with oral midazolam before the procedure also was used as needed. During the process, patients were monitored in advance of the procedure every 5 minutes by a dedicated sedation nurse via continuous pulse oximetry, heart rate, noninvasive blood pressure monitoring, and nasal capnography (with concomitant oxygen delivery via the nasal cannula). The sedating physician was readily available to assist the nurse and the patient. Patients were monitored until they awoke, drank fluids, and had a minimum Aldrete score of 9 points.21 Data are presented as mean (standard deviation) for continuous variables and frequency (percent) for categorical variables. Patients were divided into two groups: A/ASD group and the control group (without A/ASD) who required sedation for MRI. These two sedation groups were compared with respect to age, weight, heart rate, blood pressure, procedure time, and discharge time using the Student t test or the Wilcoxon rank-sum test, depending on the data distribution. Dosage and time data also were analyzed using analysis of covariance (ANCOVA) methods to adjust for demographic variables that were different between the groups. Weight was converted to z score for sex and age was based on Centers for Disease Control and Prevention reference charts, which was also used in the ANCOVA. Data were analyzed using dedicated statistical software SAS version 9.3 (SAS Institute, Cary, NC). A P < 0.05 was considered statistically significant. Results In all, 56 patients in the A/ASD group and 107 in the control group experienced no sedation failures. The age range for the A/ASD group was 1.4 to 14.7 and for the control group, the age range was 0.4 to 12.1 years. All of the patients in both groups were sedated for MRI of the brain, except 14 children, who also underwent MRI of the spine. Of these 14, 6 were in the A/ASD group and 8 were in the control group. The most common diagnosis as per the referring neurologist in the control group was seizure disorder, cerebral palsy with developmental delay, abnormal migraines, a lupus-related neurologic complication, and neoplasm. Most of the patients in the control group were neurologically normal and were taking medication to treat their pertinent disorder (eg, with an antiepileptic or baclofen to relieve their spasticity). Children in the A/ASD group were predominantly boys and older than children in the control group (Table 2). The procedure time was significantly shorter for children in the A/ASD group than those in the control group (34.62 ± 2.39 vs 44.31 ± 1.62 minutes; P < 0.05), and remained significant even after adjusting for age, weight-for-age, z score, and sex (Table 3). Table 2 Demographic and vital signs Table 3 Comparison of dexmedetomidine doses In the control group, a dexmedetomidine bolus was used once in all 107 (100%) patients, none of whom received additional medications. In the A/ASD group, a second bolus of dexmedetomidine was required in 9 (16%) patients, and 10 (18%) patients required additional IV midazolam for spontaneous movements affecting the quality of the MRI. Two patients received oral midazolam for anxiety and IV placement before the start of the procedure. On a per-kilogram basis, children in the A/ASD and control groups required a similar IV bolus of dexmedetomidine (2.55 μg/kg ± 0.14 vs 2.36 μg/kg ± 0.10; P = 0.3), with a significantly lower infusion dose in the A/ASD group (0.74 μg/kg ± 0.05 vs 0.89 μg/kg ± 0.03; P < 0.05) and remained significant after adjustment. In both groups, discharge time (time from the end of the procedure to leaving the recovery room) was long and averaged approximately 97 minutes. Children in the A/ASD group had a recovery time of approximately 7 minutes longer than those in the control group (101.2 ± 3.5 vs 94.2 ± 2.4 minutes; P < 0.05), but this time was attenuated by adjustment for age, weight, and sex (P = 0.1167). The dose of adjunct midazolam was variable, depending on the route of administration: 0.06 ± 0.07 mg/kg IV (n = 10) or 0.37 ± 0.18 mg/kg per os (n = 2). Midazolam has no effect on either induction or total doses of dexmedetomidine. One patient received additional sedation with fentanyl (1.9 mg/kg IV). Heart rates were almost similar in both groups (67.0 ± 1.6 vs 69.3 ± 1.1 beats per minute; P = 0.25). Many studies report a decrease in heart rate 20% above age-specific high limits) was observed equally in both groups (Table 2). Discussion Children with autism historically have been considered difficult to manage in medical procedures.3,22,23 Considering the prevalence of autism,24,25 the high incidence of treatable neurologic morbidity within this population,26,27 and the American Academy of Pediatrics guidelines for a neurologic evaluation of these patients,28 the availability of an effective sedation program for autistic children is paramount. The ideal sedating agent should have a rapid onset, a predictable and short duration of action, and low incidence of adverse effects. Historically, oral clonidine and ketamine have been used successfully to sedate children with ASD for different procedures; however, it is unknown whether these agents would be successful for the child with ASD receiving an MRI.3,29,30 Pentobarbital also has been used successfully for sedating pediatric patients for radiology procedures, either alone or in combination with other sedatives or narcotics for many years.10,31,32 In fact, the use of pentobarbital, either alone or with fentanyl, should provide a sedation failure rate of 30 minutes after administrating pentobarbital can occur in 1.2% to 1.4% of children.34,35 The present study describes the use of dexmedetomidine in children with A/ASD for MRI and adds to the limited data describing sedation for such procedures within this population. Dexmedetomidine alone provided effective sedation in 42 (75%) of 56 children with A/ASD and in all 107 children in the control group. The regimen appeared to be safe and was well tolerated. In our study, the doses of dexmedetomidine required by the A/ASD and control groups are higher than those initially reported for MRI sedation. Previous studies conducted in a general patient population indicated that the infusion of relatively low-dose dexmedetomidine (0.1–0.7 μg · kg−1 · hour−1) provided effective sedation36–40; however, this level of sedation likely will not be conducive to pediatric MRI sedation when higher doses of dexmedetomidine will be needed to accomplish the necessary sedation level. One previous study reported induction doses of 1 μg/kg and maintenance doses of 0.5 to 0.7 μg/kg but also reported inadequate sedation in up to 20% of recipients.15,41 Mason et al reported a large loading dose of 2 to 3 μg/kg and an infusion of 1.5 to 2 μg · kg−1 · hour−1, resulting in improved sedation success while using monotherapy in 97.6% of the 747 patients.5 Similar to the results of the present study, the higher doses appear to be well tolerated, suggesting that increasing dexmedetomidine doses may improve sedation efficacy without significantly increasing the risk. None of those studies analyzed the particular implications of dexmedetomidine in the specific patient population with A/ASD. In the present study, we specifically assess the sedation requirements in A/ASD by analyzing total, bolus, and infusion doses (Table 3). Interestingly, the infusion dose requirement was 20% less in the A/ASD group than in the control group with similar total and bolus doses (Fig. 1). The same total dose in both groups could be explained on the basis of higher weight in the A/ASD group. Given that most procedures performed required a near-motionlessness state, the goal was deep sedation. In our study, high-dose dexmedetomidine was effective as a sole agent for MRI sedation; however, 13 (23%) patients in the A/ASD group still required additional medications, such as midazolam, to minimize movements during the MRI procedure, suggesting that adjunct agents are an important part of sedation strategy for a sizeable minority of patients with ASD. Fig. 1 Total dexmedetomidine dose. Many medications often are used to treat behavioral issues such as aggression, attention-deficit/hyperactivity disorder, seizures, and anxiety and depression disorders that keep the person with an A/ASD from functioning more effectively at home or school. All of the patients in this group were taking one or more of these medications, but none of the commonly prescribed off-label medications appeared to increase the dose requirements of dexmedetomidine. Dexmedetomidine appears to have several advantages over other noninvasive, procedural sedative agents. The primary benefit is considered to be minimal respiratory depression, which is supported by our results. Other studies report no instances of hypoxic respiratory compromise, and although unrecognized hypoventilation remains possible, other series suggests this problem is rare.18,41 Another advantage of dexmedetomidine includes the combination of high efficacy with no recovery-related agitation or disorientation. This is important because recovery-related agitation can be a significant problem with both chloral hydrate6,7 and barbiturate10 sedation. This recovery pattern is especially significant in children with A/ASD because these patients are at high risk for significant sedation-related agitation or combativeness, particularly with chloral hydrate (J.W. Berkenbosch, unpublished data, 2003). These results are consistent with the findings of Lubisch et al.41 Closely related to efficacy is the issue of safety and acceptability of a sedation regimen. In the present cohort, the arterial blood pressures were not significantly different between the two groups. The heart rates decreased below preprocedure heart rates in both groups, but they were not statistically different. These decreases also could be the result of high baseline values, which in turn could have occurred because children were not premedicated for procedure anxiety (Table 1). The overall mean discharge time in our study was 101 minutes for the A/ASD group and 94 minutes for the control group (Fig. 2). The length of recovery time is relatively long compared with agents like propofol, but compares favorably with lengths reported with the use of chloral hydrate (20–120 min)6,7 and barbiturates (30–60 minutes; Fig. 3).10,11 This also is comparable to the 90-minute recovery time reported by Heard et al.42 Similarly, Lubisch et al41 reported a recovery time of 47 minutes and Mason et al5 reported a recovery time of 25 to 35 minutes, depending on the dexmedetomidine dose used. These recovery times are shorter than our discharge time; however, there is a difference between recovery time and discharge time as defined in different studies. In some studies, recovery time is reported as the time elapsed until the patient meets the discharge criteria,42 whereas we used the actual time of leaving the recovery room as the discharge time. It is probable that recovery time could be decreased by earlier discontinuation of the infusion, but this must be balanced against an increased risk of the patient waking up with subsequent movement before completion of the study. Fig. 2 Discharge time for autism/autism spectrum disorders versus control groups. Fig. 3 Recovery time for autism/autism spectrum disorders versus control groups. One issue that may be raised with our study is the difference between groups with respect to demographics (Table 1). The preponderance of boys to girls in the A/ASD group is a function of the demographics of autism, because the condition has a 4:1 male-to-female ratio. There also was a statistically significant difference between the groups for age and weight. Clinically, the difference between the sedation requirement of a 4-year-old and a 7-year-old should be insignificant because the pharmacokinetics principles would be identical for those ages.43 The fact that the A/ASD group required the same dexmedetomidine per kilogram to achieve a modified Ramsay score of 4 as did the control group supports the suggestion that children with A/ASD do not require higher doses for safe and effective procedural sedation. The limitations of our study include its retrospective nature, small group, and single-center experience. The present study presents a 100% success rate of sedation with dexmedetomidine in a difficult-to-sedate population. It could be asserted that the reported efficacy resulted from the use of an intensivist-based specialized sedation team rather than to dexmedetomidine itself. This is reasonably true to some extent because specialization and experience should increase both success and efficiency. Despite this, we can state with confidence that much of the reported success is specifically a function of dexmedetomidine. This study also is underpowered to comment on safety, because the occurrence of serious sedation related adverse effects are rare.43 Additional prospective studies of the sedation of children with A/ASD using a greater number of patients are warranted to provide a true idea of safety. Conclusions Children with A/ASD are a unique population of patients who present practitioners with challenges. With a 100% success rate, our study suggests that dexmedetomide is an attractive sedation option for children with A/ASD.
Key Points Eosinophilia was not uncommonly seen in our antiretroviral-naïve human immunodeficiency virus–infected patients (prevalence 9.7%). Skin rash was the only variable associated with eosinophilia. The majority of patients experienced resolution of eosinophilia by the end of the study. The presence of eosinophilia was not associated with human immunodeficiency virus viral suppression. An extensive workup may not be necessary. Eosinophils constitute 1% to 3% of total white blood cells.1 The upper limit of normal range for eosinophils varies from 350 to 500.1–3 Eosinophilia can be categorized into mild eosinophilia (absolute eosinophil count [AEC] 351–1500 cells per cubic millimeter), moderate eosinophilia (AEC 1500–5000 cells per cubic millimeter) or severe eosinophilia (AEC >5000 cells per cubic millimeter).1,2 Parasitic infections are the most common cause of eosinophilia worldwide,2 whereas allergic disorders are the most common cause in developed countries.1 Other etiologies of eosinophilia include familial contributors, drugs, toxins, autoimmune diseases, malignancy, and hypereosinophilic syndromes.2 Eosinophilia is well known to occur in patients infected with the human immunodeficiency virus (HIV). The prevalence of eosinophilia in this population depends on the threshold used to define it, and has been reported to be as high as 28%.4–8 HIV infection can induce the proliferation of eosinophils through a Th1-Th2 shift while decreasing the numbers of the other white blood cell components.7–9 This seems to be particularly true for patients with advanced disease (defined as a CD4 count <200 cells per cubic millimeter).7 Eosinophilia in HIV-infected patients also can be explained by reaction to medications (eg, sulfa), adrenal insufficiency, eosinophilic folliculitis, hyperimmunoglobulin E syndrome, and exfoliative dermatitis.10–13 The need for an extensive diagnostic workup for HIV-infected patients with eosinophilia is somewhat controversial. Tietz et al9 found that after an extensive workup of 15 HIV-infected patients with eosinophilia, only 1 had eosinophilia attributed to a parasitic infection. CD4 count <200 cells per cubic millimeter was the only risk factor associated with eosinophilia in their multivariate model. In another study, Skiest et al13 determined that eosinophilia in patients with advanced acquired immunodeficiency syndrome (AIDS) (mean CD4 count 25–29) was associated with cutaneous disease (eosinophilic folliculitis and atopic dermatitis) but not with other commonly associated conditions, including parasitic infections, drug reactions, or malignancy. A third study from the United Kingdom4 showed that eosinophilia among HIV-infected patients was associated with positive serology for schistosomiasis, low CD4 nadir, and prior AIDS-defining illness. In all of these studies, the prevalence of eosinophilia was determined in HIV-infected patients regardless of their use of antiretroviral therapy (ART), defined as a combination of two nucleoside/nucleotide reverse transcriptase inhibitors and either a non-nucleoside reverse transcriptase inhibitor, a protease inhibitor, or an integrase inhibitor. Using a cohort of HIV-infected, ART-naïve patients in our clinic, we sought to identify the prevalence of eosinophilia and variables associated with it. We also analyzed the impact of HIV suppression on the resolution of eosinophilia. Methods We conducted a retrospective chart review of ART-naïve HIV-infected patients initiating care at the Thomas Street Health Center (TSHC) between February 1, 2007 and January 31, 2009. In the first part of the study, we collected the following data for all patients: demographic information (age, sex, race, and country of birth) and baseline laboratory data (CD4 count, HIV viral load, white blood cell count, and AEC). We defined eosinophilia as AEC ≥400 cells per cubic millimeter (the upper limit of normal for the AEC at the TSHC laboratory). AIDS was defined as CD4 200 cells per cubic millimeter) to patients who did not have baseline eosinophilia (controls). We selected two controls per each case. We reviewed the clinical and laboratory information for cases and controls for the presence of variables associated with eosinophilia. This included clinical diagnoses at baseline (skin disorders, allergic rhinitis, asthma, hematologic malignancies, adrenal insufficiency, parasitic infections, and collagen vascular diseases); results of stool, urine, and sputum tests and serologies for parasites done in follow-up; and medication list at baseline. Finally, we collected CD4 count, AEC, and HIV viral load at the end of the study (defined as patients’ last clinic visit) for cases and controls. We also identified patients who were receiving ART and had reached ART-induced virologic suppression (defined as HIV RNA <50 copies per milliliter in at least two separate occasions during at least a 3-month period; and receipt of highly active ART for at least 6 months). The study was approved by the institutional review board of the Baylor College of Medicine and the Harris Health System research office. Statistical Analysis Descriptive statistics were used to analyze age, CD4 count, and HIV viral load. Linear regression was applied to assess any possible correlation between continuous variables (eg, AEC, CD4 count). For our case–control study, we performed a univariate analysis (Student t test for continuous variable and χ2 or Fisher exact test for categorical variables) and a multivariate logistic regression analysis for determining independent factors associated with eosinophilia. Variables with P < 0.20 in the univariate analysis were included in the multiple logistic regression models. χ2 analysis was performed to evaluate the association between resolution of eosinophilia and ART-induced viral suppression. P < 0.05 was considered to be statistically significant. We used the statistical software STATA version 12 (StataCorp, College Station, TX). Results Demographics and Characteristics of Patients There were 1169 HIV-infected patients entering care at TSHC during the study period. A total of 671 patients were highly active ART naïve (57.4%) and were included in the present study. Sixty-five ART-naïve patients had eosinophilia (defined as AEC≥ 400 cells per cubic millimeter) at baseline, resulting in a prevalence rate of 9.7%. No difference in age, sex, ethnicity, baseline CD4, or the presence of AIDS was found between patients with and without eosinophilia (Table 1). The mean baseline AEC was 159 cells per cubic millimeter (range 0–7600). Patients with eosinophilia were more likely to have higher HIV viral loads (5.05 vs 4.82 log10 copies per milliliter; P = 0.019). Total white blood cell count was higher in patients with eosinophilia compared with those without eosinophilia (6.1 cells per cubic millimeter vs 5.1 cells per cubic millimeter; P = 0.001). Table 1 Baseline characteristics of all ART-naïve HIV-infected subjects with and without baseline eosinophilia (N = 671) Comparison between Cases and Controls Fifty-two (80%) of 65 patients with eosinophilia (cases) had at least 2 follow-up clinic visits. They were matched to 104 controls. The mean baseline AEC was 592 cells per cubic millimeter for cases and 96 cells per cubic millimeter for controls. Patients with eosinophilia (cases) were more likely to demonstrate skin rash, asthma, and higher viral loads than controls in the univariate analysis (Table 2). In our multivariate analysis, only skin rash remained significantly associated with eosinophilia (odds ratio 2.16, 95% confidence interval 1.04–4.47; P = 0.04). Table 3 demonstrates the dermatologic conditions seen in cases and controls. Table 2 Comparison between patients with (cases) and without (controls) baseline eosinophilia Table 3 Dermatologic condition (N = 50) Eight patients with eosinophilia (cases) were tested for the presence of parasites. One patient was found to have a hookworm infection (diagnosed by stool ova and parasite examination). This patient was born in Guatemala. The other seven patients tested negative for parasites. Resolution of Eosinophilia Eosinophilia resolved in 38 cases (73.1%) by the end of the study (mean follow-up 1019 days). The follow-up time was longer in patients receiving ART compared with those who were not receiving ART (1115 vs 928 days; P = 0.01). The follow-up time was also longer in patients who reached HIV viral suppression by the end of the study, compared with those without HIV suppression (1184 vs 832 days; P 84%) were either from developing countries (mostly from sub-Saharan Africa) or had traveled and lived in developing countries for more than 6 weeks. Our results should be interpreted in the context of some limitations. The use of different cutoff values to define eosinophilia in other studies makes comparison of prevalence rates challenging. Only a small percentage of our patients was tested for the presence of parasites; therefore, the yield of this diagnostic approach to investigate eosinophilia remains elusive. Finally, our data may not be generalizable given the retrospective nature of the study and the fact that our center provides care primarily to male, nonwhite patients. In summary, eosinophilia in ART-naïve HIV-infected patients is not uncommon. Skin rash was the only clinical diagnosis associated with eosinophilia. HIV viral suppression does not seem to be associated with a higher likelihood of resolution of eosinophilia. For the majority of patients, an infectious disease workup may not be necessary.