Hospital Emergency Research Articles

Assessing Differential Transfusion Requirements for Children with Congenital Malformations vs. Pediatric Acute Abdomen Emergencies.

This retrospective study aimed to evaluate the efficacy of preoperative blood transfusions in correcting anemia for pediatric patients with congenital malformations (CMs) versus those with acute abdomen (AA) conditions. The study hypothesized that the response to transfusions might vary significantly between these groups due to the differences in the underlying pathology and clinical status. The study included 107 pediatric patients admitted to Timisoara 'Louis Turcanu' Emergency Hospital for Children between January 2015 and May 2023, who required blood transfusions for preoperative anemia. Hemoglobin (HGB), hematocrit (HCT), and red blood cell counts (RBC) were assessed at admission, 48 h post-transfusion, and at discharge. Statistical analyses, including Student's t-test, Pearson correlation, and chi-square tests, were utilized to compare outcomes between the groups. The study population was divided into 53 children with CM and 54 with AA. Initial analyses showed that children with CM had statistically significantly higher baseline HGB (8.54 ± 1.00 g/dL vs. 7.87 ± 1.02 g/dL, p = 0.001) and HCT (26.07 ± 3.98% vs. 23.95 ± 2.90%, p = 0.002) compared to those with AA. Post-transfusion, children with CM exhibited a greater increase in HGB, with the highest increases noted in patients with central nervous system defects (mean increase of 3.67 g/dL, p = 0.038). In contrast, the increases in HGB for children with AA were less pronounced, with the highest being 2.03 g/dL in those with peritonitis (p = 0.078). No significant gender differences were noted in response to transfusion. Children with congenital malformations respond more effectively to preoperative blood transfusions compared to those with acute abdomen conditions. These findings suggest that differential transfusion strategies may be required based on the underlying medical condition to optimize the management of preoperative anemia in pediatric patients. Tailoring transfusion approaches according to specific patient needs and conditions could enhance clinical outcomes and resource utilization in pediatric surgical settings.

Immune escape and attenuated severity associated with the SARS-CoV-2 BA.2.86/JN.1 lineage

The SARS-CoV-2 BA.2.86 lineage, and its sublineage JN.1 in particular, achieved widespread transmission in the US during winter 2023–24. However, this surge in infections was not accompanied by COVID-19 hospitalizations and mortality commensurate with prior waves. To understand shifts in COVID-19 epidemiology associated with JN.1 emergence, we compared characteristics and clinical outcomes of time-matched cases infected with BA.2.86 lineages (predominantly representing JN.1) versus co-circulating XBB-derived lineages in December, 2023 and January, 2024. Cases infected with BA.2.86 lineages received greater numbers of COVID-19 vaccine doses, including XBB.1.5-targeted boosters, in comparison to cases infected with XBB-derived lineages. Additionally, cases infected with BA.2.86 lineages experienced greater numbers of documented prior SARS-CoV-2 infections. Cases infected with BA.2.86 lineages also experienced lower risk of progression to severe clinical outcomes requiring emergency department consultations or hospital admission. Sensitivity analyses suggested under-ascertainment of prior infections could not explain this apparent attenuation of severity. Our findings implicate escape from immunity acquired from prior vaccination or infection in the emergence of the JN.1 lineage and suggest infections with this lineage are less likely to experience clinically-severe disease. Monitoring of immune escape and clinical severity in emerging SARS-CoV-2 variants remains a priority to inform responses.

Enhanced Primary Care for Severe Mental Illness Reduces Inpatient Admission and Emergency Room Utilization Rates.

Cardiovascular disease (CVD) is a leading cause of premature mortality among patients with severe mental illness (SMI). Effective care delivery models are needed to address this mortality gap. This study examines the impact of an enhanced primary care (PC) program that specializes in the treatment of patients with SMI, called Medicine in Psychiatry Service-Primary Care (MIPS-PC). Using multipayer claims data in Western New York from January 1, 2016 to December 31, 2021, patients with SMI and CVD were identified using International Classification of Diseases, Tenth Revision codes. National Provider Identification numbers of MIPS-PC providers were then used to identify those patients who were treated by MIPS-PC during the period. These MIPS-PC-treated patients were compared against a cohort of one-to-one propensity score matched contemporaneous comparison group (ie, patients receiving PC from providers unaffiliated with MIPS-PC). A difference-in-difference approach was used to identify the treatment effects of MIPS-PC on all-cause emergency department (ED) visits and hospitalization rates. The MIPS-PC group was associated with a downtrend in the acute care utilization rates over a 3-year period following the index date (ie, date of first MIPS-PC or other PC provider encounter), specifically a lower hospitalization rate in the first year since the index date (25%; P < 0.001). ED visit rate reduction was significant in the third-year period (18%; P = 0.021). In summary, MIPS-PC treatment is associated with a decreasing trend in acute care utilization. Prospective studies are needed to validate this effect of enhanced PC in patients with SMI and CVD.

Profile of Bacterial Resistance in Emergency Wards, Hospitalization, and Intensive Care Units in Mexican Hospitals with the Antimicrobial Stewardship Program

IntroductionBacterial infections are important causes of death. Some reports have shown that the COVID-19 pandemic may have had an impact on drug resistance. AimTo compare the resistance profiles between 2019 and 2020 emergency room, hospitalization non-intensive care units (ICU), and ICU areas in Mexican hospitals. MethodDatabases from 15 hospitals from 8 states in Mexico including susceptibility results for Escherichia coli, Klebsiella pneumoniae, and Pseudomonas aeruginosa collected from blood, urine, respiratory, and intra-abdominal secretions were analyzed. Different hospital areas were included: emergency room, hospitalization non-ICU, and ICU. The databases were converted using the BacLink2 tool and analyzed using the WHOnet 2022 platform. The percentage of antibiotic resistance was compared for each species and clinical specimen among years (2019 vs 2020) by a chi-square test using the criterion of p<0.05 for statistical significance. ResultsA statistically significant decrease in resistance to imipenem was observed for P. aeruginosa recovered from respiratory specimens in the ICU (55.6% vs 39.3%) and from urine samples from hospitalization non-ICU areas (52.9% vs 37.3%). Also, an increase in resistance was detected in blood isolates from hospitalization non-ICU areas for carbapenems in P. aeruginosa imipenem, (23.3 % vs 54.5%) and meropenem (27.4 % vs 49%) and in E. coli, ertapenem (2.4% vs 10.1%), imipenem (1.9% vs 13.2%), and meropenem (1.6% vs 6.8%). Also, an increase in resistance for imipenem (20.0 % vs 57.5%) and meropenem (17.6% vs 48.7 %) was detected in the emergency room for P. aeruginosa in respiratory isolates. ConclusionA decrease in carbapenem resistance for P. aeruginosa recovered from respiratory specimens in the ICU and from urine samples from hospitalization non-ICU areas was detected. In contrast, an increase in carbapenem resistance was detected for P. aeruginosa in blood isolates from hospitalization non-ICU areas and respiratory isolates from the emergency room. Regarding respiratory samples, a higher resistance for meropenem was detected in 2020 than in 2019 for K. pneumoniae (2.6 vs 10.6%, p = 0.05). These results underline the analysis of AMR in different hospital wards to focus efforts on AMR reduction.

Downstream Emergency Department and Hospital Utilization Comparably Low Following In-Person Versus Telemedicine Primary Care for High-Risk Conditions.

Telemedicine use expanded greatly during the COVID-19 pandemic. More data is needed to understand how this shift may impact other venues of acute care delivery. We evaluate the association of visit modality (telephone, video, or office) and downstream emergency department (ED) and hospital visits among primary care visits for acute, time-sensitive conditions. Observational study of patient-scheduled primary care telemedicine and office visits for acute conditions (cardiac, gastrointestinal, neurologic, musculoskeletal, and head and neck) in a large, integrated healthcare delivery system. Adults with a new self-booked primary care appointment for an eligible acute condition from January 1, 2022, to December 31, 2022 (with no primary care, ED, or hospital visits in prior 30 days). Visit modality, including office, video, or telephone. Seven-day ED and hospital utilization, adjusted for patient and visit characteristics. Among 258,958 primary care visits by 239,240 adult patients, 57.7% were telemedicine visits; of these, 72.4% were telephone and 27.6% were video. Telephone visits were the timeliest, with over 70% of visits scheduled within 1 day of booking. Rates of 7-day ED utilization were low, and varied by condition group, with cardiac visits having the highest rates (4.8%) and musculoskeletal visits having the lowest (0.8%). There was less than a 1% absolute difference in ED use by visit modality for all condition types; however, telephone visits were associated with slightly higher rates than video visits. The 7-day hospitalization rate was less than 1% and observed between visit type differences varied by clinical condition. Among office, telephone, and video visits in primary care for potentially high-risk, time-sensitive conditions, downstream ED and hospital use were uncommon. ED utilization was lower for video visits than telephone visits, although telephone visits were timelier and may offer a safe and accessible option for acute care.

Good nutritional status and oral food intake are important to be discharged to home after treatment in emergency hospital in elderly people

Good nutritional status and oral food intake are important to be discharged to home after treatment in emergency hospital in elderly people

Retrospective evaluation of implementation of caring contacts for youth suicide prevention in an emergency department.

Caring Contacts are brief caring messages sent to patients with suicidal thoughts or behaviors after an emergency department (ED) visit or hospitalization, which may decrease subsequent suicide attempts. We aimed to retrospectively evaluate the implementation of Caring Contacts in a children's hospital ED. We conducted a retrospective observational study to evaluate the implementation of Caring Contacts within routine clinical care at an academic children's hospital ED from May 2020 to April 2023. Patients 5‒18 years old presenting for suicidal thoughts or behaviors were eligible to receive six handwritten cards with individualized caring messages, mailed over 12 months. We assessed enrollment rates (the percentage of patients offered Caring Contacts who agreed to receive them), fidelity to the intended schedule and card writer, return visits for suicidal ideation or behaviors while receiving Caring Contacts, and program costs. Of 627 encounters eligible for and offered Caring Contacts, 614 (98%) resulted in enrollment. Among instances of enrollment, 587 (96%) had cards sent per the intended schedule and 541 (88%) had cards written by the intended writer. A return ED visit for suicidal ideation or behaviors occurred for 168 (27%) during program participation. Costs per participant were $4.54 in materials and 0.9h of personnel time. In a children's hospital ED, Caring Contacts were feasible to implement with low costs and high fidelity to the intended schedule and card writer. Prospective studies are needed to assess Caring Contacts' effectiveness in reducing suicide risk among adolescents following an ED visit.

Association between malnutrition risk and healthcare utilization in a culturally diverse sample of ambulatory patients with cancer.

254 Background: Malnutrition is prevalent among cancer patients placing them at an increased risk for treatment-related complications and poor clinical outcomes. This study investigated the relationship between malnutrition risk and healthcare utilization in a diverse sample of adult ambulatory cancer patients from the Sylvester Comprehensive Cancer Center. Methods: A retrospective analysis was conducted with data collected through the My Wellness Check (MWC), an electronic health record (EHR)-based assessment. Malnutrition was assessed through the NUTRISCORE, an integrated and validated nutritional screening tool within MWC that evaluates self-reported weight loss, appetite, cancer type, and treatment modality to assess risk of malnutrition. A NUTRISCORE greater or equal to 5 is considered malnutrition risk. Time to an emergency room (ER) visit and hospitalization were calculated in days from the first MWC questionnaire assignment and the first event, respectively. All ER visits and hospitalizations in the University of Miami Health System, self-reported patient demographics, and clinical characteristics were captured from the EHR. Uni- and multi-variate logistic regression models were used to examine factors associated with malnutrition risk. For survival analyses, the Kaplan-Meier method was used to calculate the cumulative incidence function of events and the cox proportional hazards regression models adjusting for patient demographics and clinical characteristics. Results: A total of5,984 ambulatory patients completed the MWC assessment between October 2019, and August 2023, with 31.2% (n=1,868) identified at malnutrition risk (NUTRISCORE ≥5). Patients were predominately White (n=5,092, 85.2%), and Hispanic (n=2,341, 39.1%). Hematologic cancer was the most common diagnosis (n=1284, 21.5%) followed by malignancies in digestive system (n=903, 15.1%) and male genitourinary (n=892, 14.9%). After adjusting for covariates, patients at malnutrition risk were at significantly higher risk for both ER visits (HR 1.57, 95% CI; 1.29 - 1.91, p&lt;0.0001) and hospitalizations (17.4% vs. 7.4% at 100 days, p&lt;0.0001) compared to those with low malnutrition risk. Factors associated with malnutrition risk included Hispanic ethnicity (aOR 1.17, 95% CI; 1.01-1.35), fatigue (aOR 1.62, 95%CI; 1.07-2.45), declined physical function (aOR 1.75, 95% CI;1.37 - 2.24), physical inactivity (aOR 1.20, 95%CI;1.04 - 1.38) and low HRQOL (aOR 2.48, 95%CI; 1.93-3.19). Conclusions: Malnutrition was associated with higher healthcare utilization in a diverse sample of ambulatory cancer patients. Hispanic ethnicity and worse PROs are factors associated with higher risk for malnutrition. Results from this work underscore the need of early nutritional interventions to prevent malnutrition and improve clinical outcomes.

S2172 Unveiling the Cost of Care: A Decadal Analysis of Emergency Department Visits and Hospital Billing Trends Using NEDS Database (2012 - 2021)

S2172 Unveiling the Cost of Care: A Decadal Analysis of Emergency Department Visits and Hospital Billing Trends Using NEDS Database (2012 - 2021)

159 A Multidisciplinary Discharge Huddle Improves Emergency Department and Hospital Throughput Measures Without Increased Readmissions in a Rural Emergency Department

159 A Multidisciplinary Discharge Huddle Improves Emergency Department and Hospital Throughput Measures Without Increased Readmissions in a Rural Emergency Department

Development and validation of a risk prediction model for acute care use among patients with advanced cancer on clinical trials.

277 Background: Patients with advanced cancer on clinical trials are at high risk for unplanned Emergency Room visits (ER_visits) and hospital stays (HS). Identifying patients at highest risk could inform personalized intervention strategies. Methods: The data were from the SWOG Cancer Research Network. Medicare claims data were linked to data from advanced cancer clinical trials. The occurrence of any HS or ER visit within 1 year after enrollment was the primary endpoint. Patients must have had 6 months of continuous Medicare claims prior to registration to determine comorbid conditions prior to treatment, and 12 months of claims after registration (or until death) to detect outcomes. We examined 23 sociodemographic (age, sex, race, ethnicity, insurance status), geographic (rural or urban, area-level deprivation), clinical (disease severity, performance status), treatment (line of therapy, therapy type), and individual comorbidity factors to establish a predictive risk model. Model derivation was conducted in a 60% random sample and tested in the remaining 40%. Best subset selection with logistic regression was used with iterative application of 3-, 4-, and 5-fold cross validation repeated 10 times. Results: Among N=1397 total patients from 6 trials (lung, 3; prostate, 2; pancreas, 1), 33.9% were 75+ years, 20.3% were female, and 8.2% were Black. The overall proportion of patients with ≥1 HS/ER visit was 68.8%. In the training set (n=839), a best 5-variable risk was identified with adverse risk factors including cancer type (prostate vs other), performance status (PS; 0 vs. &gt;=1), coronary artery disease (CAD; yes vs. no), hypertension (yes vs. no), and liver disease (yes vs. no). As cancer type was a study-level variable, we derived a risk model using PS, CAD, hypertension, and liver disease and adjusted for cancer type. There were no differences in adverse risk between those in with and without prostate cancer (interaction p-value=.44), justifying combining across cancer types. In the training set, patients with ≥2 risk factors (high risk; n=303, 36.1%) vs. 0/1 risk factor (low risk; n=536, 63.9%) had nearly a 3-fold increased odds of experiencing HS/ER visit (82.2% vs. 59.1%, OR=2.85, 95% CI, 2.01-4.03, p&lt;.001). Results were successfully validated in the test set (OR=1.93, p=.002). In all patients, those in the highest risk quartile (3/4 factors) vs the lowest risk (0 factors) had nearly a fourfold increased odds of HS/ER visits (OR=3.92, 95% CI, 2.25-6.83, p&lt;.001). Conclusions: Rates of HS_ER visits were high within the first year after enrolling on a trial for advanced cancer. We derived and validated a risk model that delineated strong differences in risk. With expansion of eligibility to include patients with more comorbid conditions, personalized interventions aimed at preventing acute care use could decrease the cost and improve the quality of cancer care.

Gender differences in outcomes of ambulatory and hospitalized patient with obesity hypoventilation syndrome

Obesity hypoventilation syndrome (OHS) is associated with high morbidity and mortality. There is a paucity of data on whether there are gender differences in outcomes. Research Question Is female gender associated with worse outcomes in ambulatory and hospitalized patients with OHS? We performed post hoc analyses on two separate OHS cohorts: 1) stable ambulatory patients from the two Pickwick randomized controlled trials and 2) hospitalized patients with acute-on-chronic hypercapnic respiratory failure from a retrospective international cohort. We first conducted bivariate analyses of baseline characteristics and therapeutics between genders. Variables of interest from these analyses were then grouped into linear mixed effects models, Cox proportional hazards models or logistic regression models to assess the association of gender on various clinical outcomes. The ambulatory prospective cohort included 300 patients (64% female) and the hospitalized retrospective cohort included 1,162 patients (58% female). For both cohorts, women were significantly older and more obese than men. Compared to men, baseline PaCO2 was similar in ambulatory patients, but higher in hospitalized women. In the ambulatory cohort, in unadjusted analysis, women had increased risk of emergency room visits. However, gender was not associated with the composite outcome of emergency room visit, hospitalization, or all-cause mortality in the fully adjusted model. In the hospitalized cohort, positive airway pressure (PAP) prescription was less prevalent in women upon discharge. In unadjusted analysis, hospitalized women had a higher mortality at 3, 6, and 12 months after hospital discharge compared to men. However, after adjusting for age, gender was not associated with mortality. Although the diagnosis of OHS is established at a more advanced age in women, gender is not independently associated with worse clinical outcomes after adjusting for age. Future studies are needed to examine gender-related health disparities in diagnosis and treatment of OHS.

Impact of supportive oncology (SO) visits on healthcare utilization.

199 Background: Palliative care (PC) has demonstrated a reduction in acute care utilization for health systems. PC input for patients with cancer has been associated with fewer emergency room visits, hospitalizations and hospital deaths in the last 30 days of life. Less is known about the upstream effects of PC referral on healthcare utilization (HCU). We examined HCU among patients in the 90 days after first SO appointment and predictors of high HCU. Methods: Patients ≥18 years with first SO consult between 01/01/2021-06/30/2023 were included. Patients who died within 90 days of their first SO appointment and incomplete utilization data were censored. Data on patient demographics, acute healthcare and hospice utilization, cancer treatment and mortality was extracted from the electronic health record (EHR). Number of ED visits in 90 days before and after first SO visit were recorded. We used descriptive statistics to describe patients’ sociodemographics, clinical characteristics and healthcare utilization. High HCU was defined as patients in the top 10% of ED visits and IP stays. Logistic regression was employed to assess whether being a high utilizer is associated with baseline characteristics. Results: We included 859 patients. On average, there were approximately 0.12, 95%CI: [0.07,0.17] more ED visits in the 90 days before the first SO appointment compared to 90 days after. There was no difference in hospitalization rates before and after the first SO appointment. Overall, 45 patients met the criteria for high HCU. The median number of ED visits and hospitalizations of high utilizers was 6 visits, compared to 1 visit for remainder of the population. There was a significant association with ethnicity with those identified as Hispanic (60%) being high HCU. There was no significant association between age, insurance status, cancer type, primary language and high HCU. High utilizers were 189% more likely to die in hospital although this did not meet statistical significance (p= 0.242). Conclusions: The findings reveal significant variations in healthcare utilization, particularly among Hispanic patients, indicating a need for targeted interventions to address these disparities. Despite no observed changes in hospitalization rates, the study emphasizes the need for further research to understand the underlying factors contributing to high healthcare utilization. Future efforts should focus on developing tailored strategies to optimize PC referrals and enhance patient outcomes across diverse populations. Race/ethnicity by utilization group. Category &lt;90th Percentile Utilization (n=814) % &gt;90th Percentile Utilization (n=45) % P value Race (%) &lt;0.001 Asian 97 (11) 0 (0) Black or African American 173 (21) 8 (18) Hispanic 198 (24) 27 (60) Other 50 (6) 3 (7) White 296 (36) 7 (16)

Outcomes After Total Knee Arthroplasty in Patients With a History of Patella Fracture: A Propensity Score-Matched Analysis.

Posttraumatic osteoarthritis is a common indication for total knee arthroplasty (TKA). The purpose of this study was to evaluate the association between a history of patella fracture and postoperative complication rates after TKA. Patients diagnosed with a patella fracture before undergoing TKA were identified from a large national database and matched to a control cohort using propensity scoring. Rates of medical complications occurring within 90 days of TKA and surgery-related complications occurring within 1 year of TKA were compared using odds ratios. Healthcare utilization outcomes including 90-day emergency department (ED) presentation, hospital readmission, and total cost were also compared. Compared with a propensity-matched control cohort, TKA patients with a history of patella fracture had a lower incidence of pulmonary embolism (OR 0.74, P = 0.0442) and higher incidences of periprosthetic joint infection (OR 1.68, P < 0.0001), revision surgery (OR 1.84, P < 0.0001), dislocation (OR 1.61, P = 0.026), lysis of adhesions (OR 2.21, P = 0.0082), and wound disruption (OR 1.52, P < 0.0001). A history of patella fracture was also associated with an increased rate of ED presentation (OR 1.08, P = 0.0454) and increased total cost ($14,359 vs. $12,786, P = 0.0003). A history of patella fracture is associated with early surgery-related complications after TKA including periprosthetic joint infection, revision surgery, dislocation, lysis of adhesions, and wound disruption. Healthcare utilization is increased among these patients with higher rates of ED presentation and increased total cost. These findings allow for more accurate risk stratification and counseling of patients. III, Retrospective review.

The John Sealy Hospital Fire Evacuation.

Advances in fire safety and building construction have made fires in modern health care facilities uncommon and easily contained. Therefore, emergent hospital evacuations resulting from an internal fire are rare. On January 4, 2017, a fire occurred at the John Sealy Hospital, part of the University of Texas Medical Branch at Galveston, resulting in emergent evacuation of the hospital building and an adjacent office and patient care building. The internal emergency response system was quickly activated, and more than 100 patients and 200 staff members were evacuated within 27 minutes with no fire- or smoke-related injuries. Obstacles encountered during the evacuation process included difficulties with communication and confirming patient count in a timely manner. This article describes the emergent hospital evacuation during the fire, summarizes the subsequent reflections of a multiagency after-action review, and issues a call to action for further research and publication on emergency patient evacuation.

Design of Prototype Phantom to Measure Quality Control for Conventional X-ray Machine Using Quantitative Image Parameters

A variety of phantoms that measure image quality parameters are commercially expensive and often complicated to use as they measure only one parameter of a particular x-ray machine, which leads to the difficulty of measuring the quality of x-ray image and thus increase the risk of radiation to the patient and society. The main objective of this study was to design a prototype phantom to measure quality control for conventional x-ray machine using quantitative image parameters. In this study, 5 conventional x-ray machines were investigated using wire phantom designed by the researcher, which consisted of variable thicknesses used to test variable exposure factors. This study introduced a more reliable method of measuring the resolution, which is modulation transfer function, which gives a complete description of the resolution instead of using full width at half maximum or the visibility method, which is more qualitative where modulation transfer function is a real quantitative method, by designing a prototype phantom that consisted of 5 wires with different thicknesses and kVp for 5 x-ray units and assessing the diagnostic x-ray machine resolution by the optimum kV found relative to machine type. This study showed that the one with the best machine resolution was Shimadzu (2011) for Khartoum Emergency Hospital, which had a high resolution of 97% at 46 kV for thickness of 1.4 mm compared with Toshiba 2011 for Almotkamil Hospital, which had 92% at 46 kVp. Also, the result showed that for the 2 types of x-ray machines the x-ray tubes do not produce the same exposure, and the output decreased with age of the x-ray unit; also, the resolution reduced when the thickness of the wires decreased.

Medicaid Accountable Care Organizations and Disparities in Pediatric Asthma Care.

Nearly 6 million children in the US have asthma, and over one-third of US children are insured by Medicaid. Although 23 state Medicaid programs have experimented with accountable care organizations (ACOs), little is known about ACOs' effects on longstanding insurance-based disparities in pediatric asthma care and outcomes. To determine associations between Massachusetts Medicaid ACO implementation in March 2018 and changes in care quality and use for children with asthma. Using data from the Massachusetts All Payer Claims Database from January 1, 2014, to December 31, 2020, we determined child-years with asthma and used difference-in-differences (DiD) estimates to compare asthma quality of care and emergency department (ED) or hospital use for child-years with Medicaid vs private insurance for 3 year periods before and after ACO implementation for children aged 2 to 17 years. Regression models accounted for demographic and community characteristics and health status. Data analysis was conducted between January 2022 and June 2024. Massachusetts Medicaid ACO implementation. Primary outcomes were binary measures in a calendar year of (1) any routine outpatient asthma visit, (2) asthma medication ratio (AMR) greater than 0.5, and (3) any ED or hospital use with asthma. To determine the statistical significance of differences in descriptive statistics between groups, χ2 and t tests were used. Among 376 509 child-year observations, 268 338 (71.27%) were insured by Medicaid and 73 633 (19.56%) had persistent asthma. There was no significant change in rates of routine asthma visits for Medicaid-insured child-years vs privately insured child-years post-ACO implementation (DiD, -0.4 percentage points [pp]; 95% CI, -1.4 to 0.6 pp). There was an increase in the proportion with AMR greater than 0.5 for Medicaid-insured child-years vs privately insured in the postimplementation period (DiD, 3.7 pp; 95% CI, 2.0-5.4 pp), with absolute declines in both groups postimplementation. There was an increase in any ED or hospital use for Medicaid-insured child-years vs privately insured postimplementation (DiD, 2.1 pp; 95% CI, 1.2-3.0 pp), an 8% increase from the preperiod Medicaid use rate. Introduction of Massachusetts Medicaid ACOs was associated with persistent insurance-based disparities in routine asthma visit rates; a narrowing in disparities in appropriate AMR rates due to reductions in appropriate rates among those with private insurance; and worsening disparities in any ED or hospital use for Medicaid-insured children with asthma compared to children with private insurance. Continued study of changes in pediatric asthma care delivery is warranted in relation to major Medicaid financing and delivery system reforms.

Pharmacological Management of Pediatric Critical Asthma.

Pediatric critical asthma, or formerly known as status asthmaticus, is a common pediatric condition encountered in emergency departments, hospital wards, and pediatric intensive care units. Systemic corticosteroids and inhaled bronchodilators are evidence-based, initial treatments for patients with pediatric critical asthma. If clinical symptoms do not improve, pediatric practitioners often prescribe adjunctive medications including inhaled anticholinergics, intravenous ketamine, intravenous magnesium, intravenous short acting beta 2 agonists, and intravenous methylxanthines (such as aminophylline). In this narrative review, we will summarize the current evidence and present the research gaps related to these therapies in the pediatric population.

Association of first antiseizure medication with acute health care utilization in a cohort of adults with newly diagnosed epilepsy.

Epilepsy is primarily treated with antiseizure medications (ASMs). The recommendations for first ASM in newly diagnosed epilepsy are inconsistently followed, and we sought to examine whether nonrecommended first ASM was associated with acute care utilization. We conducted a retrospective cohort study of adults (≥18 years old) with newly diagnosed epilepsy (identified using validated epilepsy/convulsion International Classification of Diseases, Clinical Modification codes) in 2015-2019, sampled from Marketscan's Commercial and Medicare Databases. Exposure of interest was receipt of a non-guideline-recommended ASM, and the primary outcome was acute care utilization (an emergency department visit or hospitalization after the first ASM claim). Descriptive statistics characterized covariates, and multivariable negative binominal regression models were built adjusting for age, sex, Elixhauser Comorbidity Index, comorbid neurologic disease (e.g., stroke), and ASM polypharmacy. Approximately 14 681 people with new epilepsy were prescribed an ASM within 1 year. The three most prescribed medications were levetiracetam (54%, n = 7912), gabapentin (10%, n = 1462), and topiramate (7%, n = 1022). Approximately 4% (n = 648) were prescribed an ASM that should be avoided, and ~74% of people with new epilepsy had an acute care visit during the follow-up period. Mean number of acute care visits during follow-up was 3.34 for "recommended" ASMs and 4.42 for ASMs that "should be avoided." Prescription of a recommended/neutral ASM as compared to an ASM that should be avoided was associated with reduced likelihood of acute care utilization (incidence rate ratio [IRR] = .85, 95% confidence interval [CI] = .77-.94). The recommended/neutral category of ASMs was not statistically significantly associated with seizure- or epilepsy-specific acute care utilization (IRR = .93, 95% CI = .79-1.09). Adults with new epilepsy are frequent users of acute care. There remain a proportion of persons with epilepsy prescribed ASMs that guidelines suggest avoiding, and these ASMs are associated with increased likelihood of emergency department visit or hospitalization. These findings reinforce the importance of optimizing the choice of first ASM in epilepsy.

Efficacy and feasibility of a novel semi-facial respirator with chitosan nanoparticles on the incidence of SARS-CoV-2 infection in healthcare professionals: randomized controlled trial

BackgroundEvidence suggests that semi-facial respirators provide protection against contamination in high-risk environments, although the COVID-19 pandemic called for greater protection and viral inactivation capacity. Thus, the aim of this study was to investigate the efficacy of a novel semi-facial respirator containing chitosan nanoparticles, compared with a conventional N95 respirator on the incidence of laboratory-confirmed SARS-CoV-2 in healthcare professionals. The secondary outcomes were influenza infection, usability and comfort.MethodsRandomized controlled trial within a large public hospital (reference for COVID-19 patients) carried out between March 2021 and June 2023. We included 230 healthcare professionals exposed to SARS-Cov-2 and influenza, working in emergency departments, hospital wards, and intensive care units. Participants were assessed at baseline, after 10 days, and 21 days of follow-up. Researchers, participants, and outcome assessors were blinded to the allocated groups. Outcomes were analyzed by bivariate and multivariate comparisons using logistic regression. Crude (cOR) and adjusted odds ratios (aOR) were estimated, followed by 95% confidence intervals (CIs 95%). We adopted intention-to-treat (ITT) and complete-case (CC) analyses.ResultsBaseline characteristics were considered homogeneous between groups, and usability and comfort were reported as excellent in both groups. Non-significant differences were found for all outcomes, both in the ITT and CC analyses. The incidence of COVID-19 and influenza were, respectively, cOR: 0.96 [CI95%: 0.21–4.42] and cOR: 1.25 [CI95%: 0.34–4.62]; and aOR: 1.08 [CI95%: 0.21–5.47] and aOR: 1.11 [CI95%: 0.17–7.01].ConclusionsWe found that the incidence of SARS-Cov-2 and influenza infections were similar between the new respirator compared to the conventional respirator. Furthermore, we observed that usability and comfort were similar and considered excellent for both respirators.Trial registrationClinicaltrials.gov (NCT04490200, 29/07/2020).