Hospital Status Research Articles

Physical Function and Association with Cognitive Function in Patients in a Post-COVID-19 Clinic-A Cross-Sectional Study.

Patients with long-term health sequelae of COVID-19 (post-COVID-19 condition) experience both physical and cognitive manifestations. However, there is still uncertainty about the prevalence of physical impairment in these patients and whether there is a link between physical and cognitive function. The aim was to assess the prevalence of physical impairment and investigate the association with cognition in patients assessed in a post-COVID-19 clinic. In this cross-sectional study, patients referred to an outpatient clinic ≥ 3 months after acute infection underwent screening of their physical and cognitive function as part of a comprehensive multidisciplinary assessment. Physical function was assessed with the 6-Minute Walk Test, the 30 s Sit-to-Stand Test and by measuring handgrip strength. Cognitive function was assessed with the Screen for Cognitive Impairment in Psychiatry and the Trail Making Test-Part B. Physical impairment was tested by comparing the patients' performance to normative and expected values. Association with cognition was investigated using correlation analyses and the possible explanatory variables regarding physical function were assessed using regression analyses. In total, we included 292 patients, the mean age was 52 (±15) years, 56% were women and 50% had been hospitalised during an acute COVID-19 infection. The prevalence of physical impairment ranged from 23% in functional exercise capacity to 59% in lower extremity muscle strength and function. There was no greater risk of physical impairment in previously hospitalised compared with the non-hospitalised patients. There was a weak to moderate association between physical and cognitive function. The cognitive test scores had statistically significant prediction value for all three outcomes of physical function. In conclusion, physical impairments were prevalent amongst patients assessed for post-COVID-19 condition regardless of their hospitalisation status and these were associated with more cognitive dysfunction.

Risk of post-acute sequelae of SARS-CoV-2 infection associated with pre-coronavirus disease obstructive sleep apnea diagnoses: an electronic health record-based analysis from the RECOVER initiative.

Obstructive sleep apnea (OSA) has been associated with more severe acute coronavirus disease-2019 (COVID-19) outcomes. We assessed OSA as a potential risk factor for Post-Acute Sequelae of SARS-CoV-2 (PASC). We assessed the impact of preexisting OSA on the risk for probable PASC in adults and children using electronic health record data from multiple research networks. Three research networks within the REsearching COVID to Enhance Recovery initiative (PCORnet Adult, PCORnet Pediatric, and the National COVID Cohort Collaborative [N3C]) employed a harmonized analytic approach to examine the risk of probable PASC in COVID-19-positive patients with and without a diagnosis of OSA prior to pandemic onset. Unadjusted odds ratios (ORs) were calculated as well as ORs adjusted for age group, sex, race/ethnicity, hospitalization status, obesity, and preexisting comorbidities. Across networks, the unadjusted OR for probable PASC associated with a preexisting OSA diagnosis in adults and children ranged from 1.41 to 3.93. Adjusted analyses found an attenuated association that remained significant among adults only. Multiple sensitivity analyses with expanded inclusion criteria and covariates yielded results consistent with the primary analysis. Adults with preexisting OSA were found to have significantly elevated odds of probable PASC. This finding was consistent across data sources, approaches for identifying COVID-19-positive patients, and definitions of PASC. Patients with OSA may be at elevated risk for PASC after SARS-CoV-2 infection and should be monitored for post-acute sequelae.

Availability of Primary Closure for Resection of Oral Cavity Cancer

Resection of malignant lesions in the oral and maxillofacial area causes functional and morphological defects. In order to recover from these defects, reconstruction surgery is needed, such as a primary closure or a flap. There are advantages and disadvantages to the method of using the primary closure and the flap, and the choice of procedure is entirely up to the surgeon. The purpose of this study is to evaluate the availability of primary closure in patients. For 10 years, from January 2010 to May 2020, patients who recovered using flaps after removing malignant lesions from the oral cavity and those who closed the lesion using primary closure were investigated. The investigation was conducted by searching the database of the hospital. There were 85 patients who removed malignant lesions in the oral and maxillofacial area, and among them, 16 patients closed the soft tissue defects using primary closure. Operation time, histologic types, stages, wound status, and period of hospitalization according to the patient’s medical records were investigated retrospectively. Between the staging and the primary closure, statistically significant differences were observed between stage I and stage II patients in 13 patients using the primary closure. (p = 0.046). Statistically significant differences were identified between operation time and primary closure, with an average of 4.02 h (p = 0.015). The average period of hospitality for patients who underwent primary closure was 13.4 days, compared to 26.7 days for those who underwent flap surgery. This difference was statistically significant (p = 0.0003). As a result of three-way ANOVA analysis on operation time and hospital stay, only neck incision, reconstruction method (flap or primary suture), and intrastage reconstruction method had a statistically significant effect on operation time and period of hospitality. This study evaluated the use of primary closure in patients who underwent resection of malignant lesions in the oral and maxillofacial area. Although the majority of patients underwent reconstruction with flaps, our results showed that primary closure could be a viable option for certain patients with early-stage lesions.

The relationship between safety-net hospital status and outcomes among elderly head and neck cancer patients.

The impact of safety-net status, case volume, and outcomes among geriatric head and neck cancer patients is unknown. Chi-square tests and Student's t tests to compare head and neck surgery outcomes of elderly patients between safety-net and non-safety-net hospitals. Multivariable linear regressions to determine predictors of outcome variables including mortality index, ICU stays, 30-day readmission, total direct cost, and direct cost index. Compared with non-safety-net hospitals, safety-net hospitals had a higher average mortality index (1.04 vs. 0.32, p = 0.001), higher mortality rate (1% vs. 0.5%, p = 0.002), and higher direct cost index (p = 0.001). A multivariable model of mortality index found the interaction between safety-net status and medium case volume was predictive of higher mortality index (p = 0.006). Safety-net status is correlated with higher mortality index and cost in geriatric head and neck cancer patients. The interaction between medium volume and safety-net status is independently predictive of higher mortality index.

Faktor-Faktor Yang Mempengaruhi Peningkatan Kualitas Pelayanan Kesehatan Di Instalasi Gawat Darurat: Studi Teoritis

The emergency department is the front door in providing patient safety and health services. An emergency department certainly requires a fast and precise approach to patient safety. Fast and precise handling will increase patient satisfaction, patient satisfaction is a condition where the patient's needs, desires and expectations can be met through the products and services consumed. Therefore patient satisfaction is a measure of the quality of service felt by patients divided by the patient's needs, patient desires, and expectations of the patient himself. The purpose of writing this scientific article is to find out and review from a theoretical point of view various literatures. The method used is a theoretical study by analyzing and comparing existing theories. The result of this theoretical study is its function to review the factors that become patient satisfaction, so that it can assist the Hospital in making a better plan with a more logical, rational and systematic approach for each option that will be found by forming a plan. So that it can improve the image and trust of patients in choosing health care facilities. For the hospital it is very important and needs to be done optimally with these patient satisfaction factors to support the improvement of the hospital's status. So the agency in terms of tangible, reliable, assurance, and empathy to improve patient quality.

The Effect of Pneumococcal, Influenza, and COVID-19 Vaccinations on COVID-19 Hospitalization and Progression in People over 65 Years Old Living in Nursing Homes.

Infectious diseases pose a major threat to elderly populations. Streptococcus pneumonia bacteria, influenza-causing viruses, and COVID-19 viruses cause three pathologies in the respiratory system with similar symptoms, transmission routes, and risk factors. Our study aimed to evaluate the effects of pneumococcal, influenza, and COVID-19 vaccinations on the status of COVID-19 hospitalization and progression in people over 65 years of age living in nursing homes. This study was performed in all nursing homes and elderly care centers in the Uskudar district of Istanbul.The diagnosis rate of COVID-19 was determined as 49%, the rate of hospitalization as 22.4%, the rate of hospitalization in the intensive care unit as 12.2%. The rate of intubation was determined as 10.4%, the rate of mechanical ventilation as 11.1% and the rate of COVID-19 related mortality rate as 9.7%. When the factors affecting the diagnosis of COVID-19 were examined, the presence and dose of COVID-19 vaccine was protective. When the factors affecting hospitalization status were examined, male sex and presence of chronic disease were risk factors; four doses of COVID-19 vaccine and influenza vaccine and pneumococcal vaccine together with COVID-19 vaccine were protective. When the factors affecting COVID-19-related death were examined, the male sex was a risk factor; the pneumococcal and influenza vaccine together with COVID-19 vaccine were protective. Our results revealed that the availability of influenza and pneumococcal vaccines positively impacted the progression of COVID-19 disease in the elderly population living in nursing homes.

Relationships among hospital acute ischemic stroke volumes, hospital characteristics, and outcomes in the US

Background and ObjectivesPrior research on volume-based patient outcomes related to acute ischemic stroke (AIS) have demonstrated contradictory results and fail to reflect recent advances in stroke care. We sought to examine contemporary relationships between hospital AIS volumes and outcomes. MethodsWe used complete Medicare datasets in a retrospective cohort study using validated International Classification of Diseases Tenth Revision codes to identify patients admitted with AIS from January 1, 2016 through December 31, 2019. AIS volume was calculated as the total number of AIS admissions per hospital during the study period. We examined several hospital characteristics by AIS volume quartile. We performed adjusted logistic regressions testing associations of AIS volume quartiles with: inpatient mortality, receipt of tissue plasminogen activator (tPA) and endovascular therapy (ET), discharge home, and 30-day outpatient visit. We adjusted for sex, age, Charlson comorbidity score, teaching hospital status, MDI, hospital urban-rural designation, stroke certification status and ICU and neurologist availability at the hospital. ResultsThere were 952400 AIS admissions among 5084 US hospitals; AIS 4-year volume quartiles were: 1st: 1-8 AIS admissions; 2nd: 9-44; 3rd: 45-237; 4th: 238+. Highest quartile hospitals more often were stroke-certified (49.1% vs 8.7% in lowest quartile, p<0.0001), with ICU bed availability (19.8% vs 4.1%, p<0.0001) and with neurologist expertise (91.1% vs 3%, p<0.0001). In the highest AIS quartile (compared to the lowest quartile), there was lower inpatient mortality (odds ratio [OR] 0.71 [95%CI 0.57-0.87, p<0.0001]), lower 30-day mortality (0.55 [0.49-0.62], p<0.0001), greater receipt of tPA (6.60 [3.19-13.65], p<0.0001) and ET (16.43 [10.64-25.37], p<0.0001, and greater likelihood of discharge home (1.38 [1.22-1.56], p<0.0001). However, when the highest quartile hospitals were examined separately, higher volumes were associated with higher mortality despite higher rates of tPA and ET receipt. ConclusionsHigh AIS-volume hospitals have greater utilization of acute stroke interventions, stroke certification and availability of neurologist and ICU care. These features likely play a role in the better outcomes observed at such centers, including inpatient and 30-day mortality and discharge home. However, the highest volume centers had higher mortality despite greater receipt of interventions. Further research is needed to better understand volume-outcome relationships in AIS to improve care at lower volume centers.

Incidence of acute kidney injury in dogs with systemic mycotic infections treated with amphotericin B (1996-2020).

Amphotericin-B (AmB) is an essential medication for the treatment of life-threatening systemic mycoses but the incidence and risk factors for acute kidney injury (AKI) after its administration are not known in dogs. Determine the incidence of and risk factors for AKI in dogs receiving AmB. Fifty-one client owned dogs receiving AmB for the treatment of systemic mycoses. Retrospective study. Signalment, potential risk factors, AKI development (creatinine ≥0.3 mg/dL from baseline), drug formulation (deoxycholate [AmB-D] or lipid complex [ABLC]), dose, and treatment duration were recorded. The probability of an AKI diagnosis was evaluated using a log-rank test. The incidence of AKI and odds ratios were calculated for potential risk factors. Incidence of AKI was 5/12 (42%) for dogs receiving AmB-D and 14/39 (36%) for dogs receiving ABLC. Of the 19 dogs that developed AKI, 16 (84%) continued treatment after a pause in the planned dosing protocol. Fifty percent of dogs received a cumulative dose of 6.9 mg/kg for AmB-D and 22.5 mg/kg for ABLC (P < .01) at time of AKI diagnosis. ICU hospitalization (odds ratio [OR] 0.21, 95% confidence interval [CI]: 0.58-0.87) and inpatient status (OR 0.25, 95% CI: 0.07-0.86) were associated with decreased odds of AKI. Incidence of AKI with AmB is common but does not always preclude continued treatment. The incidence of AKI is similar between AmB-D and ABLC, but dogs receiving ABLC tolerated a higher cumulative total dose before AKI diagnosis.

Abstract #1407267: In-hospital Outcomes of Myxedema Coma in Teaching Vs Non-teaching Hospitals

Many studies have analyzed current data on outcomes at teaching vs non-teaching hospitals, and the results have been found to be dissimilar in certain hospitalizations in the United States. this study set out to examine the differences in healthcare outcomes between teaching and non-teaching hospitals in patients who were admitted for myxedema coma using a nationally representative sample. We reviewed data from the National Inpatient Sample (NIS) of patients between 2016-2019. Using ICD-10 diagnosis codes, we identified patients who were admitted due to myxedema coma within the study period. We further categorized our study population into 2 groups based on teaching vs non-teaching status. Multivariate analysis was done to investigate the in-hospital outcomes between both groups and adjust for confounders. During the study period, 3,839 myxedema coma admissions were identified. Teaching hospitals received 70.7% (2,715) of these admissions, while non-teaching hospitals received 29.3% (1,124). The mean age of the cohort was 66 years, 70% were females and 69% were white. The mean length of stay (LOS) was 9.4 days and the average total hospital charge was 89,068 $. There was no significant difference in in-hospital mortality in both groups (OR 1.23, 95% CI 0.66 -2.27, p=0.507). The teaching hospital group had increased odds of acute respiratory failure (OR 1.6, 95% CI 1.07 – 2.4, p = 0.021), acute kidney injury (OR 1.48, 95% CI 1.04 – 2.1, p = 0.028), and bradycardia (OR 1.67, 95% CI 1.06 – 2.6, p = 0.025). No significant risk difference between the two groups in terms of hyponatremia (OR 0.91, 95% CI 0.6 – 1.36, p= 0.66), pericardial effusion (OR 0.87, 95% CI 0.41 – 1.8, p= 0.719) or sepsis (OR 1.38, 95% CI 0.69 – 2.7, p= 0.353). Hospital teaching status was associated with an increased mean LOS (10 vs 7.9 days, p=0.002) and mean total hospital charges (93,122 vs 79,336 $, p=0.035). The study clearly showed that patients admitted with myxedema coma in teaching hospitals have an increased risk of in-hospital outcomes including acute respiratory failure, acute kidney injury, and bradycardia compared to non-teaching hospitals. Teaching hospital status was not associated with increased in-hospital mortality in myxedema coma admissions.

Simplifying Hospital Quality Comparisons for Vascular Surgery Using Center-Level Frailty Burden Rather Than Comorbidities

Failure to rescue (FtR), or inpatient death following complication, is a publicly reported hospital quality measure. Previous work has demonstrated significant variation in the proportion of frail patients across hospitals. However, frailty is not incorporated into risk-adjustment algorithms for hospital quality comparisons and risk adjustment is made by comorbidity scores. Our aim was to assess the impact of frailty on FtR quality measurement and as a means of risk adjustment. Patients undergoing open or endovascular aneurysm repair or lower extremity bypass in the Vascular Quality Initiative (VQI) at centers performing ≥ 25 vascular procedures annually (2003-2019) were included. Multivariable logistic regression evaluated in-hospital death using scaled hierarchical modeling clustering at the center level. Center FtR observed/expected ratios were compared with expected values adjusted for either standard comorbidity profiles or frailty as measured by the VQI Risk Analysis Index. Centers were divided into quartiles using VQI-linked American Hospital Association data to describe the hospital characteristics of centers whose ranks changed. A total of 63,143 patients (213 centers) were included; 1,630 patients (2.58%) were classified as FtR. After accounting for center-level variability, frailty was associated with FtR [scaled odds ratio 1.9 (1.8-2.0), P<0.001]. The comorbidity-centric and frailty-based models performed similarly in predicting FtR with C-statistics of 0.85 (0.84-0.86) and 0.82 (0.82-0.84), respectively. Overall changes in ranking based on observed/expected ratios were not statistically significant (P=0.48). High and low performing centers had similar ranking using comorbidity-centric and frailty-based methods; however, centers in the middle of the performance spectrum saw more variability in ranking alterations. Forty nine (23%) of hospitals improved their ranking by five or more positions when using frailty versus comorbidity risk adjustment. The centers in Quartile 4, those who performed the highest number of vascular procedures annually, experience on average a significant improvement in hospital ranking when frailty was used for risk adjustment, whereas centers performing the fewest number of vascular procedures and the lowest proportion of vascular surgery cases annually (Quartile 1) saw a significant worsening of ranking position (all P<0.05). However, total number of surgical procedures annually, total hospital beds, for-profit status, and teaching hospital status were not significantly associated with changes in rank. A simple frailty-adjusted model has similar predictive abilities as a comorbidity-focused model for predicting a common quality metric that influences reimbursement. In addition to distilling the risk-adjustment algorithm to a few variables, frailty can be assessed preoperatively to develop quality improvement efforts for rescuing frail patients. Centers treating a greater proportion of frail patients and those who perform higher volumes of vascular surgery benefit from a risk adjustment strategy based on frailty.

Predicting patient-reported outcomes following lumbar spine surgery: development and external validation of multivariable prediction models

BackgroundThis study aimed to develop and externally validate prediction models of spinal surgery outcomes based on a retrospective review of a prospective clinical database, uniquely comparing multivariate regression and random forest (machine learning) approaches, and identifying the most important predictors.MethodsOutcomes were change in back and leg pain intensity and Core Outcome Measures Index (COMI) from baseline to the last available postoperative follow-up (3–24 months), defined as minimal clinically important change (MCID) and continuous change score. Eligible patients underwent lumbar spine surgery for degenerative pathology between 2011 and 2021. Data were split by surgery date into development (N = 2691) and validation (N = 1616) sets for temporal external validation. Multivariate logistic and linear regression, and random forest classification and regression models, were fit to the development data and validated on the external data.ResultsAll models demonstrated good calibration in the validation data. Discrimination ability (area under the curve) for MCID ranged from 0.63 (COMI) to 0.72 (back pain) in regression, and from 0.62 (COMI) to 0.68 (back pain) in random forests. The explained variation in continuous change scores spanned 16%-28% in linear, and 15%-25% in random forests regression. The most important predictors included age, baseline scores on the respective outcome measures, type of degenerative pathology, previous spinal surgeries, smoking status, morbidity, and duration of hospital stay.ConclusionsThe developed models appear robust and generalisable across different outcomes and modelling approaches but produced only borderline acceptable discrimination ability, suggesting the need to assess further prognostic factors. External validation showed no advantage of the random forest approach.

Relationships among Hospital Acute Ischemic Stroke Volumes, Hospital Characteristics, and Outcomes in the US (P14-5.025)

<h3>Objective:</h3> We sought to examine contemporary relationships between hospital acute ischemic stroke (AIS) volumes and outcomes. <h3>Background:</h3> Prior research on AIS volume-based patient outcomes demonstrated contradictory results and failed to reflect recent advances in stroke care. <h3>Design/Methods:</h3> We used complete Medicare datasets in a retrospective cohort study employing validated International Classification of Diseases Tenth Revision codes to identify patients admitted with AIS from January 1, 2016 through December 31, 2019. AIS volume was calculated as the total number of AIS admissions per hospital during the study period. We examined hospital characteristics by AIS volume quartile. We performed adjusted logistic regression testing associations of AIS volume with: inpatient mortality, receipt of tissue plasminogen activator (tPA) and endovascular therapy (ET), discharge home and 30-day outpatient visit. We adjusted for sex, age, Charlson comorbidity score, teaching hospital status, socioeconomic status, hospital urban-rural designation, stroke certification status, and ICU and neurologist availability at the hospital. <h3>Results:</h3> There were 952400 AIS admissions among 5084 US hospitals; AIS 4-year volume quartiles were: 1st: 1–8 AIS admissions; 2nd: 9–44; 3rd: 45–237; 4th: 238+. Highest quartile hospitals more often were stroke-certified (49.1% vs 8.7% in lowest quartile, p&lt;0.0001), with ICU bed availability (19.8% vs 4.1%, p&lt;0.0001) and with neurologist expertise (91.1% vs 3%, p&lt;0.0001). For every ten-unit increase in volume, there were higher odds of receiving tPA (OR 1.009, 95% CI 1.008–1.01, p&lt;0.0001) and ET (1.041, 1.037–1.046, p&lt;0.0001), but also higher inpatient mortality (1.004, 1.003–1.005, p&lt;0.0001) and 30-day mortality (1.001, 1.001–1.002, p&lt;0.0001). <h3>Conclusions:</h3> High AIS-volume hospitals have greater utilization of acute stroke interventions, stroke certification and availability of neurologist and ICU care. Despite these advantages, higher AIS volumes were associated with increased inpatient and 30-day mortality. Further research is needed to better understand volume-outcome relationships in AIS to provide effective stroke care and accurately risk-adjust hospital outcomes. <b>Disclosure:</b> Dr. McCarthy has nothing to disclose. Dr. Daniel has nothing to disclose. Dr. Santos has nothing to disclose. Dr. Dhamoon has received personal compensation in the range of $10,000-$49,999 for serving as an Expert Witness for Faegre Baker Daniels LLP. Dr. Dhamoon has received personal compensation in the range of $10,000-$49,999 for serving as an Expert Witness for Wellstar Health System Inc. Dr. Dhamoon has received personal compensation in the range of $10,000-$49,999 for serving as an Expert Witness for Fabiani Cohen &amp; Hall, LLP. Dr. Dhamoon has received personal compensation in the range of $5,000-$9,999 for serving as an Expert Witness for Kramer, Dillof, Livingston &amp; Moore. Dr. Dhamoon has received personal compensation in the range of $500-$4,999 for serving as an Expert Witness for Robins Kaplan. Dr. Dhamoon has received personal compensation in the range of $5,000-$9,999 for serving as an Expert Witness for Parker Waichman LLP. Dr. Dhamoon has received personal compensation in the range of $500-$4,999 for serving as an Expert Witness for Heidell, Pittoni, Murphy &amp; Bach, LLP.

Investigating the association of measures of epigenetic age with COVID-19 severity: evidence from secondary analyses of open access data

Epigenetic modifications may contribute to inter-individual variation that is unexplainable by presently known risk factors for COVID-19 severity (e.g., age, excess weight, or other health conditions). Estimates of youth capital (YC) reflect the difference between an individual's epigenetic - or biological - age and chronological age, and may quantify abnormal aging due to lifestyle or other environmental exposures, providing insights that could inform risk-stratification for severe COVID-19 outcomes. This study aims to thereby a) assess the association between YC and epigenetic signatures of lifestyle exposures with COVID-19 severity, and b) to assess whether the inclusion of these signatures in addition to a signature of COVID-19 severity (EPICOVID) improved the prediction of COVID-19 severity. This study uses data from two publicly-available studies accessed via the Gene Expression Omnibus (GEO) platform (accession references: GSE168739 and GSE174818). The GSE168739 is a retrospective, cross-sectional study of 407 individuals with confirmed COVID-19 across 14 hospitals in Spain, while the GSE174818 sample is a single-center observational study of individuals admitted to the hospital for COVID-19 symptoms (n = 102). YC was estimated using the (a) Gonseth-Nusslé, (b) Horvath, (c) Hannum, and (d) PhenoAge estimates of epigenetic age. Study-specific definitions of COVID-19 severity were used, including hospitalization status (yes/no) (GSE168739) or vital status at the end of follow-up (alive/dead) (GSE174818). Logistic regression models were used to assess the association between YC, lifestyle exposures, and COVID-19 severity. Higher YC as estimated using the Gonseth-Nusslé, Hannum and PhenoAge measures was associated with reduced odds of severe symptoms (OR = 0.95, 95% CI = 0.91-1.00; OR = 0.81, 95% CI = 0.75 - 0.86; and OR = 0.85, 95% CI = 0.81-0.88, respectively) (adjusting for chronological age and sex). In contrast, a one-unit increase in the epigenetic signature for alcohol consumption was associated with 13% increased odds of severe symptoms (OR = 1.13, 95% CI = 1.05-1.23). Compared to the model including only age, sex and the EPICOVID signature, the additional inclusion of PhenoAge and the epigenetic signature for alcohol consumption improved the prediction of COVID-19 severity (AUC = 0.94, 95% CI = 0.91-0.96 versus AUC = 0.95, 95% CI = 0.93-0.97; p = 0.01). In the GSE174818 sample, only PhenoAge was associated with COVID-related mortality (OR = 0.93, 95% CI = 0.87-1.00) (adjusting for age, sex, BMI and Charlson comorbidity index). Epigenetic age is a potentially useful tool in primary prevention, particularly as an incentive towards lifestyle changes that target reducing the risk of severe COVID-19 symptoms. However, additional research is needed to establish potential causal pathways and the directionality of this effect.

Predictors of Delayed Diagnosis of Pediatric CNS Tumors in the Emergency Department.

Central nervous system (CNS) tumor diagnoses are frequently delayed in children, which may lead to adverse outcomes and undue burdens on families. Examination of factors associated with delayed emergency department (ED) diagnosis could identify approaches to reduce delays. We performed a case-control study using data from 2014 to 2017 for 6 states. We included children aged 6 months to 17 years with a first diagnosis of CNS tumor in the ED. Cases had a delayed diagnosis, defined as 1 or more ED visits in the 140 days preceding tumor diagnosis (the mean prediagnostic symptomatic interval for pediatric CNS tumors in the United States). Controls had no such preceding visit. We included 2828 children (2139 controls, 76%; 689 cases, 24%). Among cases, 68% had 1 preceding ED visit, 21% had 2, and 11% had 3 or more. Significant predictors of delayed diagnosis included presence of a complex chronic condition (adjusted odds ratio [aOR], 9.73; 95% confidence interval [CI], 6.67-14.20), rural hospital location (aOR, 6.37; 95% CI, 1.80-22.54), nonteaching hospital status (aOR, 3.05, compared with teaching hospitals; 95% CI, 1.94-4.80), age younger than 5 years (aOR, 1.57; 95% CI, 1.16-2.12), public insurance (aOR, 1.49, compared with private; 95% CI, 1.16-1.92), and Black race (aOR, 1.42, compared with White; 95% CI, 1.01-1.98). Delayed ED diagnosis of pediatric CNS tumors is common and frequently requires multiple ED encounters. Prevention of delays should focus on careful evaluation of young or chronically ill children, mitigating disparities for Black and publicly insured children, and improving pediatric readiness in rural and nonteaching EDs.

Early response to COVID-19 in Brazil: The impact of a targeted approach to suspected cases and on epidemiological surveillance efforts

BackgroundSevere acute respiratory syndrome coronavirus 2 (SARS-CoV-2) entered Brazil before travel restrictions and border closures were imposed. This study reports the characteristics of suspected and confirmed coronavirus disease 2019 (COVID-19) cases among symptomatic international travelers in Brazil and their contacts. MethodsThe REDCap platform developed by the Brazilian Ministry of Health was analyzed to identify and investigate suspected cases of COVID-19 recorded during the period January 1 to March 20, 2020. The impact of Brazil's targeted approach to suspected cases from specific countries on epidemiological surveillance efforts during the early stages of the COVID-19 pandemic were analyzed. ResultsBased on molecular RT-PCR tests, there were 217 (4.2%) confirmed, 1030 (20.1%) unconfirmed, 722 (14.1%) suspected, and 3157 (61.6%) non-investigated cases among travelers returning from countries included on the alert list for surveillance, as defined by the Ministry of Health. Among the 3372 travelers who went to countries not included on the alert list, there were 66 (2.0%) confirmed, 845 (25.3%) unconfirmed, 521 (15.6%) suspected, and 1914 (57.2%) non-investigated cases. A comparison of the characteristics of confirmed cases returning from alert and non-alert countries did not reveal a statistically significant difference in symptoms. Almost half of the hospitalized travelers with known travel dates and hospitalization status (53.6%) were inbound from countries not included on the alert list, and RT-PCR tests were reported for only 30.5%. ConclusionsPolicies adopted at entry points to contain the introduction of SARS-CoV-2 in Brazil were not ideal. An analysis of the early response shows that surveillance of travelers, including testing strategies, data standards, and reporting systems, was insufficient.

Analysis of Hospital Operating Margins and Provision of Safety Net Services

Safety net hospitals (SNH) provide many community services. The cost of providing these services is unknown. To determine what safety net criteria are associated with differences in hospital operating margin. This cross-sectional study of US acute care hospitals from 2017 to 2019 included eligible hospitals identified from US Centers for Medicare & Medicaid Services Cost Reports. Five domains of SNH: undercompensated care measured using the Disproportionate Share Hospital index, uncompensated care, essential community services, neighborhood disadvantage, and sole community hospital and critical access hospital status. Each was categorized as a quintile or binary response. Covariates included hospital ownership, size, teaching status, census region, urbanicity, and wage index. Operating margin and its association with each safety net criterion was determined using linear regression adjusting for all safety net criteria and covariates. A total of 4219 hospitals were analyzed, of which 3329 hospitals (78.9%) satisfied at least 1 safety net criterion; 23 hospitals (0.5%) met 4 or all 5 criteria. Among safety net criteria, the highest quintile of undercompensated care (-6.2 percentage point difference compared with lowest quintile; 95% CI, -8.2 to -4.2 percentage points), uncompensated care (-3.4 percentage points; 95% CI, -5.1 to -1.6 percentage points), and neighborhood disadvantage (-3.9 percentage points; 95% CI, -5.7 to -2.1 percentage points) were each associated with a lower operating margin. No association with operating margin was found between critical access or sole community hospital status (0.9 percentage points; 95% CI, -0.8 to 2.7 percentage points) or the highest vs lowest quintile of essential services (0.8 percentage points; 95% CI, -1.2 to 2.7 percentage points). Among essential services, burn, inpatient psychiatry, and primary care services were associated with lower operating margin, while others were either not associated or showed positive association. Fall-off in operating margin by level of uncompensated care was most severe in the highest percentiles of uncompensated care, with the most marked declines among those with the lowest operating margin. In this cross-sectional study of SNH, hospitals in the highest quintiles of undercompensated care, uncompensated care, and neighborhood disadvantage were more financially vulnerable than those not in the top quintile, especially when they met numerous of these criteria. Ensuring targeting of financial support to these hospitals could improve their financial stability.

Hospitalization status and gender recognition over the arboviral medical records using shallow and RNN-based deep models

In global health systems, clinicians have a challenging decision of a triage patient exposed to arbovirus infections to determine they should be hospitalized. Diagnosing symptoms and molecular testing can be uncertain and costly, especially in resource-limited settings. However, machine learning approaches have a high potential to determine through medical record examination whom to hospitalize. The purpose of this study is to determine hospitalized or outpatient individuals correctly by implementing shallow machine learning algorithms on SISA (Severity Index for Suspected Arbovirus) and SISAL (Severity Index for Suspected Arbovirus with Laboratory) datasets. Feed Forward Neural Network (FFNN), Probabilistic Neural Network (PNN), and Decision Tree (DecT) algorithm with three splitting criterions were used to process the SISA and SISAL datasets. The results of classification performances demonstrated that improved area under the curve scores (0.973) and accuracy (reaching up to 98.73% with FFNN) were obtained when compared with previous research study related to machine learning and arbovirus. Moreover, this study also aims to investigate gender recognition over arboviral infection medical records using recurrent neural network-based deep models. Hence vector control policy in the health system reflects the gender roles to control the spread of arboviral infection. Overall the outcomes are potentially very promising.

Assessment of Library Services at Top-Performing Pediatric Hospitals in the Southeast United States

The authors compare and contrast the structure and function of librarians and library services using a convenience sample online survey of pediatric hospitals in the Southeast based on the rankings from the Regional U.S. News & World Report Best Children’s Hospitals and Magnet status. This approach is intended to determine how librarians and library services at hospitals that are recognized by the above programs differ from those that are not recognized.

Association of developmental milestones with vitamin B12 and folate status among hospitalized severe acute malnutrition children at a tertiary care center in North India

Abstract Introduction: Severe acute malnutrition (SAM) is a severe form of malnutrition affecting nearly 20 million children worldwide. Besides increasing the risk of death and disease, malnutrition also leads to growth retardation and impaired psychosocial and cognitive development. Vitamin B12 and folate are water-soluble essential micronutrients critical in average growth and development, particularly during infancy and childhood. A deficiency of folate and vitamin B12 can result in anemia, poor growth, and increased infections, and vitamin B12 deficiency can cause irreversible neurologic damage to the developing brain. We conducted this study to assess serum folate and vitamin B12 levels in children with SAM at admission and determine its relation with their developmental milestones. Materials and Methods: One hundred admitted SAM children between ages 6 and 59 months were taken to assess serum folate and vitamin B12 levels status in a tertiary care hospital and determine its relation with their developmental milestones. Results: The majority of the participants were in the age group 6–12 months (64%), rural (95%), the lower class of socioeconomic status (76%), and incomplete immunization (63%). Serum vitamin B12 and folate levels were found to be significantly associated with different domains of childhood development. Conclusion: This analysis revealed a high prevalence of vitamin B12 deficiency among malnourished children aged 6–59 months. We found that serum vitamin B12 level and folic acid were significantly associated with developmental delay in all domains (gross motor, fine motor, language, and social) of milestones.

Early Use of Aspirin after Symptoms in Patients with ST-Segment Elevation Myocardial Infarction Undergoing Percutaneous Coronary Intervention

Objectives: To determine the frequency of pre-hospital aspirin use in patients presenting with ST- segment elevation myocardial infarction and to assess the demographic and clinical characteristics of the patients taken pre-hospital aspirin. Methodology: It was a prospective study conducted at tertiary care hospital for the duration of six months. About 657 patients aged between 18-80 years, of either gender and diagnosed with ST-elevation myocardial infraction were included in the study. Use of pre-hospital aspirin after symptoms was assessed in all patients, then followed and outcomes such as discharge status and length of hospital in days were evaluated. Results: Overall mean age was 54.60±12.06 years and most of them were males (79.1%). About 254 patients (38.7%) received aspirin before transfer to hospital and 403 patients (61.3%) received aspirin after arrival in hospital. Frequency of pre-hospital use of aspirin was significantly associated with gender (p=0.001), educational status (p=0.006), and monthly income (p=0.003). The mean rank of length of hospital stay was similar significantly lower in STEMI patients who received pre-hospital aspirin as compared to those who did not receive pre-hospital aspirin (p=0.001). Moreover, the death rate was lower in patients with pre-hospital aspirin administration as compared to those who did not receive pre-hospital aspirin (1.2%vs2%). However, the difference between pre-hospital aspirin use and discharge status was not statistically significant (p=0.434). Conclusion: Frequency of pre-hospital aspirin use was lower in patients with STEMI. Gender, educational status, and socio-economic status were the significant factors for pre-hospital aspirin use.