Objectives. To determine whether historical redlining practices were associated with emergency department (ED) presence and capabilities in 2001 and 2022. Methods. Using a repeated, cross-sectional design, we linked census tract-level Home Owners' Loan Corporation classifications to ED locations and characteristics from the National ED Inventory-USA survey in 2001 and 2022. We modeled odds of ED presence and ED capabilities with Home Owners' Loan Corporation classification as the primary predictor variable. We adjusted the models for 2022 using contemporary demographics. Results. Neighborhoods with a Home Owners' Loan Corporation classification of best, compared with hazardous, had higher odds of an ED being present in 2001 (odds ratio [OR] = 1.42; 95% confidence interval [CI] = 1.04, 1.90), which persisted in 2022 (OR = 1.73; 95% CI = 1.26, 2.37) after adjusting for contemporary demographics. Nonredlined neighborhoods had higher odds of ED presence than did redlined neighborhoods, driven by nonacademic EDs. The odds of having advanced ED capabilities did not differ across Home Owners' Loan Corporation classifications; however, nonredlined neighborhoods had significantly lower odds of ED capabilities. Conclusions. Although historical redlining classifications were associated with ED presence over time, redlining classification was not associated with current ED capabilities. (Am J Public Health. Published online ahead of print July 23, 2026:e1-e7. https://doi.org/10.2105/AJPH.2026.308568).

BackgroundEmergency department (ED)-based teletrauma service may improve access to trauma expertise, especially in rural areas. However, its impact on patient outcomes remains unclear due to limited understanding of how and what type of care is delivered. The objective of this study was to characterize how EDs in the United States (US) use teletrauma services in clinical practice.MethodsNon-federal/non-specialty EDs, that previously reported using teletrauma, were surveyed in the 2023 National Emergency Department Inventory Teletrauma Survey. The survey was developed and mailed/emailed to ED directors up to two times; nonresponders were contacted via telephone. Survey assessed structural and process measures including staffing, workflows, clinical care, and resource availability. Descriptive statistics were used.ResultsAmong 378 EDs that reported using teletrauma in 2022, 310 responded (82%). Only 68% (211/310) reported using teletrauma in 2023. Most teletrauma-using EDs (TT-EDs) used the service once a month or less (58%), were staffed by non-emergency medicine (EM)-trained providers for in-person care (69%) and EM-trained physicians for remote care (72%). Consults were usually initiated at the discretion of the in-person provider (80%) and often after the patient's arrival to the ED (46%). Clinical applications included decision-support for interfacility transfers (78%), resuscitation-support (71%), documentation (69%) and remote procedural-support (64%) for patients of all ages. Some TT-EDs received trauma education from teletrauma-providing sites (30%), but few reported receiving resources, such as blood products (4%).ConclusionTeletrauma is not widely used in US EDs. Even when capabilities exist, teletrauma use remains limited and insufficiently adapted to rural trauma care.

This cross-sectional study determines the additional population access to trauma care expertise provided by telehealth for trauma in emergency departments and provides updated national estimates of trauma center access.

Background:Post-bronchiolitis asthma is often associated with impaired lung function. Identifying biological mechanisms for lung function impairment in children with post-bronchiolitis asthma is important because it may provide an opportunity for early intervention. Therefore, we sought to analyse nasal airway metabolome signatures that are associated with lung function impairment in children with post-bronchiolitis asthma. Methods:We performed a cross-sectional analysis of nasal airway metabolome and lung function in children with an asthma diagnosis by age 6 years in a subset from the 35th Multicenter Airway Research Collaboration. We profiled nasal airway metabolome at age 6 years. Using a weighted gene co-expression network analysis approach, we identified metabolite modules. We also examined how metabolite modules and their constituent individual metabolites associate with lung function. Results:This study included 116 children with an asthma diagnosis by age 6 years and available nasal airway samples. We identified seven distinct metabolite modules in the metabolome data. The peptide and amino acid derivatives module was significantly correlated with bronchodilator response at age 6 years (false discovery rate (FDR)=0.040). Three modules (peptide and amino acid derivatives; urea cycle, aromatic and branched-chain; and N-acetylated amino acid modules) were significantly correlated with forced vital capacity (FDR=0.048). Three metabolites from the peptide and amino acid derivatives module were significantly associated with bronchodilator response: palmitoyl-sphingomyelin (odds ratio (OR) 1.62, 95% confidence interval (CI) 1.07-2.99, FDR=0.047), N-acetylthreonine (OR 1.63, 95% CI 1.20-2.43, FDR=0.048) and pyridoxate (OR 3.81, 95% CI 1.13-4.40, FDR=0.048). We found that 25 metabolic pathways were differentially enriched (FDR<0.05), e.g. arginine biosynthesis and histidine metabolism. Conclusions:The findings suggest that nasal airway metabolomic signatures may reflect pathogenetic mechanisms that underly lung function impairment in post-bronchiolitis asthma.

BACKGROUND:The gut microbiome is thought to influence risk of childhood allergic diseases; however, the data on species-level links to childhood asthma and lung function are limited, and the role of host genetics in the gut-lung axis remains unclear. METHODS:In a multicenter cross-sectional study of children with a history of bronchiolitis from the 35th Multicenter Airway Research Collaboration, we performed shotgun metagenomic profiling of stool samples obtained at age 6 years and examined associations of the gut microbiome with asthma prevalence and lung function. We also calculated polygenic risk scores (PRSs) of asthma and lung function to investigate the interaction between host genetics and the gut microbiome in relation to these traits. RESULTS:In the 300 children included for this study, 3 bacterial species (ie, Bacteroides vulgatus, Eisenbergiella massiliensis, and Butyricimonas virosa) were differentially associated with FEV1 value and 4 bacterial species were differentially associated with ratio of FEV1 value to forced vital capacity (FVC) (eg, Bifidobacterium longum) (false discovery rate [FDR] according to the R package MaAsLin < 0.25). Furthermore, host genetics-gut microbiome interaction analysis showed association of B vulgatus (FDR = 0.037) and Bacteroides uniformis (FDR = 0.037) with FEV1/FVC ratio among children with a high FEV1/FVC ratio PRS. Additionally, Ruminococcus bromii (FDR = 0.067) and Alistipes indistinctus (FDR = 0.13) were suggested to have protective associations with asthma, specifically in children with a high asthma PRS, indicating that host genetics can modulate the effect of the gut microbiome on these respiratory outcomes. CONCLUSION:By applying the metagenomic approach to a multicenter cohort of children with a history of bronchiolitis during infancy, this study suggests potential interplay of host genetics with the gut microbiome, as well as their integrated relationship with childhood asthma and lung function.

OBJECTIVE:Emergency department (ED) capabilities, such as trauma center or stroke center designation, are key to understanding the effects of emergency medical services (EMS) transport destination decisions on patient outcomes. In current EMS datasets, ED capabilities are self-reported by the EMS clinician or agency. The reliability and validity of the EMS-reported ED capabilities is unknown. Our objective was to link EMS transport destinations with verified ED capability data to develop a novel national dataset to better understand prehospital routing practices. METHODS:We linked two cross-sectional databases: the 2021 ESO Data Collaborative and the 2021 National Emergency Department Inventory (NEDI)-USA. The ESO Data Collaborative contains de-identified prehospital patient care records from nearly 2,000 participating EMS agencies across the United States. The NEDI-USA is a survey of all nonfederal, non-specialty U.S. EDs open 24/7/365 (including freestanding EDs), with verified stroke, trauma, and burn capability data. From EMS records, we obtained all unique destinations designated as "hospital" as of 2021. After verifying addresses were NEDI-eligible EDs (i.e., providing emergency services 24/7/365), we performed a 3-step linkage process to NEDI-USA: (1) name/address exact matches; (2) probabilistic matching on name/address based on bigrams, accepting adequate (>85%) match scores after review; and (3) hand-matching using Google Maps. We calculated descriptive statistics to describe the linkage process. RESULTS:Of the 9,420 unique "hospital" destinations in the EMS dataset, 2,714 (29%) were non-hospital facilities (e.g., nursing home) or were non-NEDI-eligible (e.g., specialty hospital such as a psychiatric facility). We linked 98% (n = 6,605/6,706) of NEDI-eligible EMS hospital transport destinations to EDs in NEDI-USA. Excluding duplicate addresses for a single hospital (e.g., ED address versus main entrance address), the linked addresses represented 3,877 unique EDs in 49 states, which included 68% (n = 3,821/5,580) of the EDs included in the 2021 NEDI-USA database. CONCLUSIONS:We successfully linked 98% of EMS ED transport destinations to verified ED capability information. This novel linked dataset now includes rich destination capability information associated with each EMS transport that can be leveraged for describing and improving routing practices for specific patient conditions, such as patients with stroke-like symptoms to stroke centers or major traumas to verified trauma centers.

STUDY OBJECTIVE:Recent initiatives have aimed to improve emergency care for older adults by supporting the recognition of geriatric emergency departments (GEDs). Our objective was to create a unified database of GEDs to understand the distribution and growth of US GEDs. METHODS:We identified United States emergency departments (EDs) that were members of the Geriatric ED Collaborative (GEDC) or accredited by the Geriatric ED Accreditation (GEDA) program by December 31, 2022. For completeness, we also identified hospitals recognized by the Age Friendly Health Systems (AFHS), although this recognition is not ED-specific. We collected the year each facility first received recognition and incorporated the combined list into the 2022 National ED Inventory-US database. RESULTS:We identified 324 GEDs (5.8%) among 5,622 nonfederal EDs in 2022. An additional 202 hospitals were recognized by AFHS, yielding 526 (9.4%) potential GEDs (pGEDs). GEDs (and pGEDs) were disproportionally located in urban areas. From 2017 to 2019, 110 (69%) of 160 pGEDs were in nonteaching hospitals, and from 2020 to 2022, 316 (86%) of 366 were. This rise in nonteaching hospital pGEDs was driven largely by AFHS hospitals, but a similar pattern was observed among GEDs (GEDC and GEDA). Attainment of GEDA was more likely among EDs in GEDC (odds ratio 13.56, 95% confidence interval 6.14 to 29.96) than AFHS-recognized hospitals (odds ratio 3.26, 95% confidence interval 2.15 to 4.95). CONCLUSIONS:The different requirements of GEDC, GEDA, and AFHS-along with current findings-support inclusion of GEDC or GEDA only in the unified national GED database. Furthermore, there was an increase in the number of pGEDs in nonteaching hospitals since 2017. We encourage further efforts to expand these 2 ED-based programs into nonurban, community EDs.

Emergency department (ED) capabilities, such as trauma center or stroke center designation, are key to understanding the effects of emergency medical services (EMS) transport destination decisions on patient outcomes. In current EMS datasets, ED capabilities are self-reported by the EMS clinician or agency. The reliability and validity of the EMS-reported ED capabilities is unknown. Our objective was to link EMS transport destinations with verified ED capability data to develop a novel national dataset to better understand prehospital routing practices. We linked two cross-sectional databases: the 2021 ESO Data Collaborative and the 2021 National Emergency Department Inventory (NEDI)-USA. The ESO Data Collaborative contains de-identified prehospital patient care records from nearly 2,000 participating EMS agencies across the U.S. The NEDI-USA is a survey of all non-federal, non-specialty U.S. EDs open 24/7/365 (including freestanding EDs), with verified stroke, trauma, and burn capability data. From EMS records, we obtained all unique destinations designated as "hospital" as of 2021. After verifying addresses were NEDI-eligible EDs (i.e., providing emergency services 24/7/365), we performed a 3-step linkage process to NEDI-USA: 1) name/address exact matches; 2) probabilistic matching on name/address based on bigrams, accepting adequate (>85%) match scores after review; and 3) hand-matching using Google Maps. We calculated descriptive statistics to describe the linkage process. Of the 9,420 unique "hospital" destinations in the EMS dataset, 2,714 (29%) were non-hospital facilities (e.g., nursing home) or were non-NEDI-eligible (e.g., specialty hospital such as a psychiatric facility). We linked 98% (n = 6,605/6,706) of NEDI-eligible EMS hospital transport destinations to EDs in NEDI-USA. Excluding duplicate addresses for a single hospital (e.g., ED address versus main entrance address), the linked addresses represented 3,877 unique EDs in 49 states, which included 68% (n = 3,821/5,580) of the EDs included in the 2021 NEDI-USA database. We successfully linked 98% of EMS ED transport destinations to verified ED capability information. This novel linked dataset now includes rich destination capability information associated with each EMS transport that can be leveraged for describing and improving routing practices for specific patient conditions, such as patients with stroke-like symptoms to stroke centers or major traumas to verified trauma centers.

The association between early childhood serum 25-hydroxyvitamin D (25(OH)D) and eosinophilic asthma remains unclear. We investigated this association using multicentre prospective data from 584 children with a history of bronchiolitis requiring hospitalisation (high-risk population). Low serum 25(OH)D levels (<20 ng/mL) were associated with increased odds of developing eosinophilic asthma (adjusted OR 2.33; 95% CI 1.23, 4.40; p=0.01) as compared with children with serum 25(OH)D of 20–39.9 ng/mL. Our data facilitate further investigation into the potential role of early-life vitamin D supplementation among children with a history of severe bronchiolitis and eosinophilia for preventing childhood asthma.

BACKGROUND:The absence of a standardized asthma definition in epidemiologic studies undermines the consistency of incidence estimates and the comparability of clinical outcomes. OBJECTIVE:To evaluate the impact of integrating bronchodilator response (BDR) into parent-reported asthma definitions by comparing incidence, disease severity, control, and diagnostic performance across these definitions, and to assess the individual diagnostic performance of BDR and fractional exhaled nitric oxide in identifying asthma cases. METHODS:We used data from a prospective cohort of 919 infants with severe (hospitalized) bronchiolitis to explore 4 asthma definitions: (1) broad, any physician diagnosis of asthma by age 6 years, as reported by parents; (2) epidemiologic, definition 1 plus either asthma medication use (eg, inhaled bronchodilator, inhaled corticosteroid, systemic corticosteroid, and montelukast) or asthma-related symptoms between ages 5.0 and 5.9 years; (3) alternative strict, definition 2 plus a post-BDR increase of 8% or greater in predicted forced expiratory volume in 1 second; and (4) strict, definition 2 plus a post-bronchodilator increase of more than 10% in predicted forced expiratory volume in 1 second. Outcomes were assessed across these definitions, and their diagnostic performance was compared with a physician reviewer's asthma diagnosis (reference standard). RESULTS:The incidence rates for the 4 definitions were 37.2%, 27.7%, 13.2%, and 9.3%, respectively, with intermittent asthma severity classification following a similar pattern (72.4%, 65.5%, 56.0%, and 52.8%). Transitioning from the first to the fourth definition improved specificity and positive predictive value but reduced sensitivity, with no consistent trends being observed for asthma control across definitions. CONCLUSION:These findings suggest that incorporating BDR into parent-reported asthma definitions underestimates asthma incidence and identifies cases with worse clinical outcomes.

Objectives:The growth of nonphysician emergency department (ED) practitioners and the rural shortage of emergency physicians have raised concerns about the declining presence of physicians in EDs. Our objective was to identify the percentage of US EDs without 24/7 attending physician coverage and to investigate the location and characteristics of these EDs. Methods:The National ED Inventory (NEDI)-USA survey is sent annually to the ED director of every nonfederal US ED. The 2022 survey (administered in 2023 to all EDs open during 2022) included the question: "Is at least one attending physician (not resident) on duty in the ED 24 h/d?" The NEDI-USA database includes basic ED characteristics such as annual visit volume, critical access hospital (CAH) status, rural location, and freestanding ED status. We investigated the association of ED characteristics with a lack of 24/7 attending physician coverage. Results:The 2022 NEDI-USA database identified 5622 EDs, of which 4621 (82%) responded to the 24/7 attending physician question. Overall, 344 of 4621 (7.4%) EDs reported the absence of 24/7 attending physician coverage. In several states, ≥30% of the state EDs lacked 24/7 coverage; the states with the highest percentages were North Dakota (58%), South Dakota (56%), and Montana (46%). Among these 344 EDs, 318 (92%) had annual visit volumes <10,000. Most EDs (307 [89%] of 344) were in a CAH; 248 (72%) were rural, and 6 (2%) were freestanding. Conclusion:Approximately 1 in 13 US EDs lacks 24/7 attending physician coverage. The absence of 24/7 attending physician coverage was more common in low-volume EDs and CAHs. These observations highlight important gaps in ED care nationally. Changes in CAH regulations may help address this important workforce issue.

BACKGROUND:Bronchiolitis exposes infants to both acute burdens (e.g., hospitalization in cases of severe bronchiolitis) and increased risks for chronic respiratory sequelae (e.g., asthma). In severe bronchiolitis, recent evidence suggests distinct pathobiological roles of microbiota (e.g., viruses, bacteria) and host responses influenced by genetic and epigenetic factors. However, the relationship of airway microbiota with host DNA methylation (DNAm) in infants with severe bronchiolitis remains unknown. METHODS:In a multi-center prospective cohort of 504 multi-ethnic infants with severe bronchiolitis (age < 1 year), using nasopharyngeal microbiome (exposure) and blood DNAm (outcome, Infinium MethylationEPIC BeadChip, Illumina) data within 24 h of the hospitalization, we conducted microbiome-epigenome-wide association studies (mbEWAS). We examined microbiota-associated differentially methylated CpGs (mbDMCs, false discovery rate [FDR] < 0.05), regions (mbDMRs, FDR < 0.05), and DNAm age acceleration. We also determined the associations of DNAm age acceleration with asthma development by age 6 years. Furthermore, we focused on asthma-related pathogenic bacteria-Haemophilus influenzae, Moraxella catarrhalis, and Streptococcus pneumoniae-for functional analyses by examining serum mbDMR-related proteins (Proseek Multiplex, Olink) and their enriched pathways (FDR < 0.10). RESULTS:Across 23 common taxa-observed at least in 25% of the infants, we identified 1 mbDMC (S. pneumoniae, cg16594639, chr20: 39528675) and 96 mbDMRs (e.g., S. pneumoniae, chr5:27038497-27038802, CDH9; chr6:48068669-48068940, PTCHD4). A higher H. influenzae abundance was associated with DNAm age deceleration, and the deceleration was associated with a higher risk of developing asthma. In 29 mbDMRs of the asthma-related pathogenic bacteria, we identified 156 mbDMR-related proteins (e.g., MMP9, XCL1). These proteins were enriched in immune response-related pathways (e.g., regulation of ERBB signaling and eosinophil chemotaxis and migration pathways). CONCLUSIONS:In this multi-center prospective cohort study of severe bronchiolitis, our mbEWAS suggested the microbiota-host associations that regulate immune responses.

Background Our objective was to describe emergency medical services (EMS) transport destination practices for patients with suspected stroke using a novel linked data set of EMS patient care data and verified emergency department (ED) stroke‐related capabilities. Methods This was a cross‐sectional evaluation of EMS 9‐1‐1 encounters for patients with suspected stroke from 2019 to 2021 from the ESO Data Collaborative, linked to verified ED capabilities from the 2021 National ED Inventory‐USA survey. Our primary outcome was transport to an ED with any stroke care capabilities. We used mixed effects logistic regression models with a random intercept for agency to estimate the odds of transport to an ED with stroke care capabilities. We used intraclass correlation coefficients and median odds ratios (ORs) to quantify the contribution of covariates and variability between EMS agencies. Results The analytic sample included 314 642 encounters (median age 72 years, 53% female) from 1781 EMS agencies, including 719 (40%) agencies primarily serving rural areas. Overall, 32 142 (10%) patients were transported to facilities lacking verified stroke care capabilities. There was significant between‐agency variation, with median ORs consistently >2.0 (eg, fully adjusted model, median OR, 3.91 [95% CI, 3.71–4.11]). Rural, versus urban, location was associated with lower odds of transport to an ED with stroke care capabilities (OR, 0.15 [95% CI, 0.14–0.17]). Conclusions In this analysis of EMS encounters, 1 in 10 patients with suspected stroke was transported to a facility without verified stroke care capabilities. Variation across EMS agencies and lower odds of appropriate routing in rural settings highlight critical gaps in prehospital stroke systems of care.

The authors declare no conflicts of interest. Data S1. Please note: The publisher is not responsible for the content or functionality of any supporting information supplied by the authors. Any queries (other than missing content) should be directed to the corresponding author for the article.

INTRODUCTION:Severe bronchiolitis (i.e., bronchiolitis requiring hospitalization) is linked to childhood asthma development. Despite a growing understanding of risk factors for developing post-bronchiolitis asthma, protective factors remain unclear. In this study, we aimed to investigate whether exposure to residential greenness between birth and bronchiolitis hospitalization is associated with asthma and atopic asthma development by age 6 years. METHODS:We analyzed a US severe bronchiolitis cohort from hospitalization to age 6 years, investigating how the normalized difference vegetation index (NDVI) and chlorophyll index green (CI green), measured in small (100 m) and large (500 m) radiuses around homes, relate to asthma and atopic asthma by age 6 years. We also explored whether maternal antibiotic use, daycare attendance, and respiratory virus type during hospitalization act as effect modifiers. RESULTS:The study cohort included 861 infants, with 239 (28%) developing asthma by age 6 years-152 atopic, 17 nonatopic, and 70 unclassified. Early life residential exposure to high NDVI and CI green levels was associated with lower odds of asthma (ORAdj for NDVI within a 100 m radius, 0.18; 95% CI, 0.05-0.78; and ORAdj for CI green levels within a 100 m radius, 0.53; 95% CI, 0.31-0.90). Associations also were significant for the development of atopic asthma (ORAdj 0.16; 95% CI, 0.03-0.96; and ORAdj 0.46; 95% CI, 0.25-0.92; respectively). Results were similar for the 500 m radius exposures. No effect modification was noted. CONCLUSION:In a U.S. bronchiolitis cohort, exposure to residential greenness between birth and bronchiolitis hospitalization is linked to lower asthma and atopic asthma risk by age 6 years.

Objectives Prior research suggests that the presence of state-specific pediatric emergency medical facility recognition programs (PFRPs) is associated with high emergency department (ED) pediatric readiness. The PFRPs aim to improve the quality of pediatric emergency care, but individual state programs differ. We aimed to describe the variation in PFRP characteristics and verification requirements and to describe the availability of pediatric emergency care coordinators (PECCs) in states with PFRPs. Methods In mid-2020, we collected information about each PFRP from 3 sources: the state Emergency Medical Services for Children (EMSC) website, the EMSC Innovation and Improvement Center website, or via communication with the state's EMSC program manager. For each state with a PFRP, we documented program characteristics, including program start date, number of tiers, whether participation was required/optional, and requirements for verification. Results Overall, we identified 17 states with active PFRPs. Five states had only 1 tier or level of recognition whereas the others had multiple. All programs did require presence of a PECC for verification. However, some PRFPs with multiple verification tiers did not require presence of a PECC to achieve each level of verification. In states with PFRPs, EDs with higher total visit volumes, a separate pediatric ED area, located in the Northeast, and earlier program start date were all more likely to have a PECC. Conclusions There is variation in state PFRPs, although all prioritize the presence of a PECC. We encourage further research on the effect of different aspects of PFRPs on patient outcomes.

Immunoglobulins play a vital role in host immune response and in the pathogenesis of conditions like asthma. Therapeutic agents such as monoclonal antibodies target specific elements of the asthmatic inflammatory cascade. Decisions to utilize these medications are often based on systemic inflammatory profiling without direct insight into the airway inflammatory profile. We sought to investigate the relationship between immunoglobulin and cytokine profiles in the airway and systemic immune compartments of adult asthmatics. Blood sampling and bronchoscopy with bronchoalveolar lavage (BAL) were performed in 76 well-defined adult asthmatics. Antibody and cytokine profiles were measured in both BAL and serum using ELISA and quantibody arrays. There was no relationship between BAL and serum levels of IgE. This is of significance in an asthma population. For some analytes, correlation analysis was significant (P < 0.05) indicating representativeness of our cohort and experimental setup in those cases. Nevertheless, the predictive power (r2) of the BAL-to-serum comparisons was mostly low except for TNF-α (r2 = 0.73) when assuming a simple (linear) relationship. This study highlights the importance of sample site when investigating the roles of immunoglobulins and cytokines in disease pathogenesis and suggests that both localized and systemic immune responses are at play. The prescription of asthma monoclonal therapy is generally based on systemic evaluation of cytokine and immunoglobulin levels. Our research suggests that this approach may not fully reflect the pathophysiology of the disease and may provide insight into why some patients respond to these targeted therapies while others do not.