Emergency department resource utilization among nursing home residents, a National Cross-Sectional Study.

OBJECTIVES: Persons 65 years and older (older persons), particularly residents of nursing homes (NHs), disproportionately access the emergency department (ED) and utilize more medical resources. The goal of this study is to provide a contemporary description of healthcare utilization patterns and disposition decisions for United States (US) NH residents presenting to EDs. METHODS: Older persons presenting to EDs in the US were identified in the National Hospital Ambulatory Medical Care Survey (NHAMCS) 2017, 2018 and 2019 datasets. We examined demographic, clinical, and resource use characteristics and outcomes. After survey weighting, we compared the frequency of different imaging, medications, clinical interventions, and outcomes in the ED between NH residents and those residing outside NHs. RESULTS: From 2017 to 2019, older persons made 24,441,285 annual visits to the ED, comprising 17.5% of all visits. Among these, 1,579,916 visits (6.5%) were by NH residents. Compared with non-NH residents, NH residents were older (mean age: 81.2 [95%CI 81.5-82.9] vs 76.1 [95%CI 75.8-76.4]), underwent more imaging (82.8% [95%CI 79.5-86.1] vs 71.6% [95%CI 69.9-73.3]), were administered fewer potentially inappropriate medications (PIMs) in the ED or upon discharge (9.5% [95%CI 6.2-2.7] vs 17.1% [95%CI 15.8-18.4]), and had a higher proportion of visits resulting in hospital admission (44.1% [95%CI 38.2-49.9] vs 26.0% [95%CI 23.3, 28.7]). CONCLUSIONS: Older NH residents presenting to the ED use more resources and are more likely to be hospitalized compared to older persons residing outside NHs. The resource-intensive nature of these visits highlights the importance of targeted, multi-disciplinary interventions that optimize ED care for this population.

Stress During Pregnancy Associated with Newborn Low Birth Weight: Experiences from the State of Rhode Island.

PURPOSE: Prenatal stress is a known risk for poor birth outcomes. This study specifically looked at reported stress during pregnancy and low birth weight (LBW) in Rhode Island. METHODS: Pregnancy Risk Assessment Monitoring System (PRAMS) data from 2016 to 2018 for the state of Rhode Island was utilized. Stress during most recent pregnancy was dichotomized as: 'none to minimal' and 'moderate to high.' LBW was defined as less than 2,500 g. Multivariable regression analysis was performed, accounting for complex survey design. RESULTS: In this cohort, 24% of pregnant people reported moderate to high stress leading to an adjusted odds of 1.70 (95% CI 1.43-2.03) of having a LBW newborn compared to those with none to minimal stress. Primiparity, previous preterm birth, racism, smoking history, and history of chronic medical problems were also associated with LBW newborns. CONCLUSION: We recommend screening and provision of support services for stress in all settings where pregnant people access care.

The Association of Antenatal Depression and Cesarean Delivery among First-Time Parturients: A Population-Based Study.

OBJECTIVE: Antenatal depression (AD) has been considered a risk factor for cesarean delivery (CD); however, the supporting data are inconsistent. We used a large, nationally representative dataset to evaluate whether there is an association between AD and CD among women delivering for the first time. STUDY DESIGN: We utilized the 2016 to 2019 Multistate Pregnancy Risk Assessment Monitoring System (PRAMS) from the Centers for Disease Control. First-time parturients who reported depression in the 3 months prior to or at any point during their recent pregnancy were compared with those who did not. The mode of delivery was obtained through the birth certificate. Maternal demographics, pregnancy characteristics, and delivery characteristics were compared by the report of AD using bivariable analyses. Population-weighted multivariable regression was performed, adjusting for maternal age, race/ethnicity, insurance, pregnancy complications, preterm birth, and body mass index (BMI). RESULTS: Of the 61,605 people who met the inclusion criteria, 18.3% (n = 11,896) reported AD and 29.8% (n = 19,892) underwent CD. Parturients with AD were younger, more likely to be non-Hispanic white, publicly insured, use tobacco in pregnancy, deliver earlier, have lower levels of education, higher BMIs, and more medical comorbidities (hypertension and diabetes). After adjustment for these differences, there was no difference in risk of CD between those with AD compared with those without (adjusted odds ratio: 1.04; 95% confidence interval: 0.97-1.13). CONCLUSION: In a large, population-weighted, nationally representative sample of first-time parturients, there was no association between AD and CD. KEY POINTS: · Antenatal depression is increasingly common and has multiple known morbidities.. · Prior data on antenatal depression and cesarean delivery are mixed.. · We found no association between depression and cesarean delivery..

Do Unmet Health Needs Drive Pediatric Emergency Department Utilization?: A Population-Based Assessment.

OBJECTIVE: Lack of access to basic health services is thought to increase emergency department (ED) utilization. This study assessed the relationship between unmet health care needs and pediatric ED utilization in the United States. METHODS: The National Survey of Children's Health was used (2016-2017; n = 71,360). Parent/guardians reported number of ED visits and the presence of unmet health needs (medical, dental, mental health, vision, hearing, other) in the last 12 months. Associations were analyzed using multinomial logistic regression modeling and accounted for the weighting and complex survey design of the National Survey of Children's Health. RESULTS: Children with 2 or more unmet health needs had 3.72 times (95% confidence interval, 2.25-6.16) risk of ≥2 ED visits when compared with those with 0 unmet health needs. This risk became nonsignificant when adjusted for race, ethnicity, age, insurance, having asthma, current medication status, health description, number of preventative health visits, and place to go for preventative health (aRR, 1.77; 95% confidence interval, 0.96-3.27). The adjusted association was also nonsignificant for specific types of unmet needs. Race, insurance status, age 0 to 3 years, current medication status, having asthma, ≥2 preventative visits, and poorer health were associated with ≥2 ED visits. CONCLUSIONS: Unmet health needs were not found to be a significant driving force for ED utilization. Other factors were found to be more strongly associated with it. Future studies to understand the perception, motives, and complex interaction of various factors leading to ED use in high-risk populations may optimize care for these children.

Sounding the Alarm on Sleep: A Negative Association Between Inadequate Sleep and Flourishing.

OBJECTIVE: To assess the national prevalence of inadequate sleep among school-age children and its relationship with childhood flourishing. STUDY DESIGN: This cross-sectional study analyzed 49 050 parental responses from the 2016-2017 National Survey of Children's Health for school-age children. Inadequate sleep duration was defined as <9 hours for 6- to 12-year-olds and <8 hours for 13- to 17-year-olds on an average weeknight. Five markers of flourishing were examined individually and as a combined measure. Logistic regression was used with complex survey design and applied weights. RESULTS: Inadequate sleep was found in 36.4% of 6- to 12-year-olds and in 31.9% of 13- to 17-year-olds. Compared with children with adequate sleep, 6- to 12-year-olds with inadequate sleep had increased odds of not showing interest and curiosity in learning (aOR, 1.61; 95% CI, 1.34-1.94), not caring about doing well in school (aOR, 1.45; 95% CI, 1.23-1.71), not doing homework (aOR, 1.44; 95% CI, 1.24-1.68), and not finishing tasks (aOR, 1.18; 95% CI, 1.03-1.35). Children aged 13-17 years with inadequate sleep had increased odds of not doing homework (aOR, 1.36; 95% CI, 1.17-1.58), not staying calm and in control when challenged (aOR, 1.34; 95% CI, 1.16-1.54), not showing interest and curiosity in learning (aOR, 1.34; 95% CI, 1.14-1.58), not finishing tasks (aOR, 1.20; 95% CI, 1.03-1.40), and not demonstrating the combined flourishing measure (aOR, 1.35; 95% CI, 1.17-1.56). CONCLUSIONS: Nationally representative data show that one-third of school-age children have inadequate sleep. Inadequate sleep is associated with decreased flourishing. These data will help inform sleep policies and optimize child development.

Childhood Obesity Is Associated with Poor Academic Skills and Coping Mechanisms.

OBJECTIVE: To assess the relationship between obesity and select childhood flourishing markers including academic skills and coping strategies. STUDY DESIGN: Cross-sectional study utilizing parental reported data for children aged 10-17 years (n = 22 914) from the 2016 National Survey of Children's Health. Multiple binary regressions assessed the association between body mass index-for-age and 5 school-related and behavioral childhood flourishing markers independently and combined, including completing homework, showing interest in learning, finishing tasks, staying calm when challenged, and caring about academics. Analyses were adjusted for age, sex, depression, sleep, digital media exposure, poverty, and parental education level. RESULTS: Only 28.9% of children with obesity were reported to have all 5 markers, compared with 38% with overweight, and 40.5% with normal body mass index. In an adjusted model, children with obesity had significantly decreased odds of demonstrating 4 of 5 markers: showing interest in learning (aOR, 0.78; 95% CI, 0.62-0.97), finishing tasks (aOR, 0.77; 95% CI, 0.63-0.94), staying calm when challenged (aOR, 0.73; 95% CI, 0.59-0.90), and caring about academics (aOR, 0.69; 95% CI, 0.55-0.86). Completing homework was not associated with obesity. Youth with obesity also had 23% decreased odds (aOR, 0.77; 95% CI, 0.61-0.98) of meeting the combined measure for flourishing markers. CONCLUSIONS: Childhood obesity is associated with poor academic skills and coping strategies which may lead to worse individual and public health outcomes. Further studies are needed to create validated flourishing measures and identify interventions that promote healthy youth behavior and academic success.

Higher education associated with better national tetanus vaccination coverage: A population-based assessment.

Vaccination coverage among United States (U.S.) adults for tetanus continues to be lower than the national goals. Education has demonstrated a positive impact on vaccination coverage. However, recently there have been outbreaks of vaccine preventable conditions in areas with high college completion rates. This study assessed the relationship between education and tetanus vaccination. Data from the 2016 Behavioral Risk Factor Surveillance System (BRFSS), a self-reported annual survey for non-institutionalized adults in the US from the Centers for Disease Control, was analyzed in 2019. The outcome was up-to-date tetanus vaccination if received within the last 10 years. Education was categorized into 1) grade 11 or less, 2) grade 12/GED, 3) college 1-3 years, and 4) college 4 or more years. Bivariate analyses and multivariable logistic regression were conducted on the analytic sample (n = 417,473) using Stata 15, accounting for weighting and the complex survey design. In 2016, 59.9% of U.S. adults had up-to-date tetanus vaccination. Higher education level was associated with increased odds of up-to-date tetanus vaccination. The highest odds were for those with 4 or more years of college education [aOR = 1.31; 95% (CI: 1.26-1.35)]. Female sex, Black (non-Hispanic), unemployed, not being married, not having insurance or a personal health care provider, and above 45 years of age had lower odds of up-to-date tetanus vaccination. Targeted community specific vaccination education programs for those without tertiary education may help enhance the knowledge and thus the overall vaccination status in the U.S.

The Inverse Relationship between Digital Media Exposure and Childhood Flourishing.

OBJECTIVE: To describe the relationship between digital media exposure (DME) and parental perception of childhood flourishing, or overall positive well-being. It is hypothesized that there is an inverse association between parent-reported measures of childhood flourishing and increasing daily DME. STUDY DESIGN: Parental responses for children ages 6-17 years (N = 64 464) from the 2011-2012 National Survey of Children's Health were analyzed. Average weekday DME that was not school work related was categorized in 2-hour intervals: 0 to <2, 2 to < 4, 4 to < 6, and ≥6 hours. Bivariate analyses and logistic regression models were used to examine the relationship between DME and parent-reported frequency of 5 childhood flourishing markers: completing homework, caring about academics, finishing tasks, staying calm when challenged, and showing interest in learning. RESULTS: Only 31% reported <2 hours of weekday DME. For the remaining children, daily DME was 2 to <4 hours (36%), 4 to <6 hours (17%), or ≥6 hours (17%). In a model adjusted for age, sex, race, poverty level, primary language spoken at home, and highest maternal education level, there was a dose-dependent decrease in the odds of demonstrating all 5 markers of flourishing as weekday DME increased (test for trend for each outcome P < .001). In stratified analyses, this relationship held true regardless of the child's age group, sex, or poverty level. CONCLUSION: This study provides evidence that, among school-aged children, increasing weekday DME has an inverse dose-dependent relationship with multiple childhood flourishing markers.

Emergency Department Visits Owing to Intentional and Unintentional Traumatic Brain Injury among Infants in the United States: A Population-Based Assessment.

OBJECTIVE: To examine national trends of emergency department (ED) visits owing to traumatic brain injury (TBI) among infants (age <12 months), specifically in the context of intentional and unintentional mechanisms. STUDY DESIGN: National Electronic Injury Surveillance System-All Injury Program data documenting nonfatal ED visits from 2003 to 2012 were analyzed. TBI was defined as ED visits resulting in a diagnosis of concussion, or fracture, or internal injury of the head. Intentional and unintentional injury mechanisms were compared using multivariable models. Joinpoint regression was used to identify significant time trends. RESULTS: TBI-related ED visits (estimated n = 713 124) accounted for 28% of all injury-related ED visits by infants in the US, yielding an average annual rate of 1722 TBI-related ED visits per 100 000 infants. Trend analysis showed an annual increase of 9.48% in the rate of TBI-related ED visits over 10 years (P < .05). For these visits, an estimated 701 757 (98.4%) were attributed to unintentional mechanisms and 11 367 (1.6%) to intentional mechanisms. Unintentional TBI-related ED visit rates increased by 9.52% annually (P < .05) and the rates of intentional TBI were relatively stable from 2003 to 2012. Infants with intentional TBI were more likely to be admitted (aOR, 11.44; 95% CI, 3.02-21.75) compared with those with unintentional TBI. CONCLUSIONS: The rate of TBI-related ED visits in infants increased primarily owing to unintentional mechanisms and intentional TBI-related ED visits remained stable over the decade. Improved strategies to reduce both intentional and unintentional injuries in infants are required.

Point-of-Care Ultrasound Assessment of Bladder Fullness for Female Patients Awaiting Radiology-Performed Transabdominal Pelvic Ultrasound in a Pediatric Emergency Department: A Randomized Controlled Trial.

STUDY OBJECTIVE: Radiology-performed transabdominal pelvic ultrasound, used to evaluate female patients with suspected pelvic pathology in the pediatric emergency department (ED), is often delayed by the need to fill the bladder. We seek to determine whether point-of-care ultrasound assessment of bladder fullness can predict patient readiness for transabdominal pelvic ultrasound more quickly than patient sensation of bladder fullness. METHODS: We performed a randomized controlled trial of female patients aged 8 to 18 years who required transabdominal pelvic ultrasound in a pediatric ED. Patients were randomized to usual care or point-of-care ultrasound and then assessed every 30 minutes for subjective bladder fullness (0 to 4 ordinal scale) and qualitative bladder fullness by point-of-care ultrasound. Patients were sent for pelvic ultrasound when they reported 3 or 4 on the subjective fullness scale (usual care) or a large bladder was visualized (point-of-care ultrasound). Primary outcome was time from enrollment to completion of pelvic ultrasound. Secondary outcome was success rate of pelvic ultrasound on first attempt. RESULTS: One hundred twenty patients were randomized and 117 had complete outcomes (59 usual care, 58 point-of-care ultrasound). Kaplan-Meier curves differed between groups (P<.001). Median time to successful completion of pelvic ultrasound was 139 minutes (usual care) and 87.5 minutes (point-of-care ultrasound), with difference in medians 51.5 minutes (95% confidence interval [CI] 23.4 to 77.2 minutes). All point-of-care ultrasound patients had successful transabdominal pelvic ultrasound on the first attempt compared with 84.7% in the usual care group, with difference -15.3% (95% Bayesian credible interval -5.3% to -25.0%). Weighted κ for interrater agreement was 0.83 (95% CI 0.79 to 0.87). CONCLUSION: Point-of-care ultrasound assessment of bladder fullness decreases time to transabdominal pelvic ultrasound and improves first-attempt success rate for female patients in the pediatric ED.

Emergency Department Utilization Among Assault-Injured Youth: Implications for Youth Violence Screening.

OBJECTIVE: Assault is a common cause of youth emergency department (ED) visits. Little is known about prior ED utilization patterns among assault-injured youth. This study's objectives were to determine whether, and how, prior ED visit history distinguishes assault-injured youth from unintentionally injured youth. METHODS: A 5-year retrospective, case-control study was conducted using a hospital billing database. Youth ages 13 to 24 years presenting to the ED of an urban level 1 trauma center in 2011 with an E-code of physical assault- or weapon-related injuries were compared 1:1 to randomly assigned, age- and sex-matched controls with an E-code corresponding to unintentional injury. Bivariate, t test, Wilcoxon rank sum tests, and conditional logistic regression were performed to determine how previous ED visits distinguished assault-injured youth from unintentionally injured youth. RESULTS: In 2011, 964 patients presented with assault-related injuries. Over the previous 5 years, assault-injured youth had a median of 1 prior ED visit (interquartile range, 0-3); unintentionally injured youth had a median of zero prior ED visits (interquartile range, 0-2). Assault-injured youth had significantly higher median numbers of previous psychiatric and assault-related ED visits when compared to unintentionally injured youth. A youth with 1 previous psychiatric ED visit had a 4-fold increased odds (adjusted odds ratio [AOR], 4.05; 95% confidence interval, 2.41-6.83) of having a 2011 assault-related ED visit compared to unintentionally injured youth. CONCLUSIONS: Assault-injured youth are more likely to have had prior ED use particularly for psychiatric illnesses and assault-related injury. Targeted youth violence screening may be appropriate for such patients.

The Association of Parental Coping and Childhood Injury.

Objectives Injuries are the leading cause of pediatric morbidity and mortality in the United States. Interaction between child, parent and environmental factors may contribute to injuries. This study investigates the association between coping with parenthood and injuries in children age 0-5 years. Methods In this cross-sectional observational study, we analyzed data from the 2007 National Survey of Children's Health, a random-digit-dialing, nationally-representative telephone survey. Information was obtained from a caregiver about children 5 years of age or younger. Parental coping with the demands of parenthood was categorized into three groups-"very well", "somewhat well" and "not very well" or "not very well at all". Injury was defined as caregiver report of any injury within the previous 12 months that required medical attention. Results This study included 27,471 surveys about children 5 years of age or younger. With weighted analysis, 10.4 % of children were reported to have an injury; 31.1 % of caregivers reported coping with parenthood "somewhat well" and 1.7 % reported coping "not very well"/"not very well at all". The adjusted odds ratio of sustaining an injury was 1.26 (95 % CI 1.00, 1.59) for children of parents who reported coping somewhat well with the demands of parenthood compared to those with parents coping very well. Conclusions Parental report of coping with parenthood less than very well was associated with injury in children ages 0-5 years, further highlighting the importance of the interaction between parent factors and childhood injury.

Presentation to either the pediatric emergency department or primary care clinic for acute illness: the caregivers' perspective.

OBJECTIVES: This study aimed to understand and compare caregivers' perceptions of and attitudes toward care received in a primary care clinic (PCC) versus that received in the pediatric emergency department (PED) as well as the reasons for selecting either location to receive care for their child. METHODS: Surveys were administered to caregivers of children who receive their primary care at the same location who presented for a nonurgent sick visit to either the PCC or PED during regular PCC hours. RESULTS: One hundred fifty-one caregivers in the PCC and 83 in the PED completed the survey. Compared with caregivers who brought their child to the PED, those who presented to the PCC were more likely to report that the child had been sick for more than 2 days (P < 0.001), indicate that the child could wait more than 3 hours to be seen (P < 0.001), have called the PCC for advice (odds ratio [OR], 5.2; 95% confidence interval [CI], 2.9-9.2), have spoken with a nurse (OR, 3.7; 95% CI, 2.0-6.7), be satisfied with their phone call to the PCC (OR, 12.2; 95% CI, 6.4-23.1), and report that they could easily get in touch with the PCC (OR, 3.6; 95% CI, 1.8-7.3). Most caregivers who went to the PCC felt that it was more convenient (98.6%) and they would be seen more quickly (95.8%). CONCLUSIONS: Although all children had the same medical home, caregivers who presented to the PCC were more likely to have called the clinic, spoken with a nurse, and reported greater satisfaction with the PCC than those who brought their child to the PED.

Prescribing Patterns for Postpartum Contraception Among Breastfeeding Patients Insured Under Medicaid in Rhode Island: A PRAMS Analysis.

INTRODUCTION: Disparities in contraceptive counseling are well documented in the United States. People of color, those of lower socio-economic status, and Medicaid insurance are more likely to receive contraception/sterilization counseling than White patients. Postpartum contraceptive choice is an important aspect for pregnant people, especially for those who plan to breastfeed. This study assessed postpartum contraception/sterilization prescription among breastfeeding people in Rhode Island insured under Medicaid compared to other insurance carriers. METHODS: Secondary analysis of data from the Rhode Island Pregnancy Risk Assessment Monitoring System (PRAMS) from 2016-2019. Participants who answered yes to 'having ever breastfed' were included and dichotomized based on insurance into 'Medicaid' or 'other insurance'. Primary outcome was postpartum contraception/sterilization prescription. Stata software version 15 was used to perform multivariable logistic regression accounting for complex survey design and weighting. RESULTS: Of 3686 participants, 868 (24.4%) were insured under Medicaid. Medicaid participants were younger, had higher BMIs and were more likely to identify as Black or mixed race or Hispanic ethnicity than those with other insurers. Those insured under Medicaid were 1.5 times more likely to be prescribed postpartum contraception than those with other insurers (95% CI 1.26,1.78). After adjusting for race/ethnicity, education level, marital status and preterm delivery, those with Medicaid were 1.28 times more likely to be prescribed contraception (95% CI 1.05,1.57). CONCLUSION: In this study, breastfeeding participants with Medicaid were more likely to be prescribed postpartum contraception than those with other insurances. Future research should be focused on assessing provider bias, contraception coercion, and initiatives to provide equitable and patient-centered counseling in this population.

Increasing computed tomography use for patients with appendicitis and discrepancies in pain management between adults and children: an analysis of the NHAMCS.

STUDY OBJECTIVE: Using a national sample of emergency department (ED) visits, we aim to describe use of CBC, computed tomography (CT), and pain medication among ED visits in which appendicitis was diagnosed. We describe use trends over time and identify use differences between adults and children. METHODS: The ED component of the National Hospital Ambulatory Medical Care Survey was analyzed for 1992 through 2006, comprising a sample of 447,011 visits (representing an estimated total of approximately 1.5 billion visits), from which a sample of 1,088 patients (representing an estimated 3.7 million patients) received a diagnosis of appendicitis. The frequency of CBC and CT use and frequency of pain medication administration were determined. Survey-adjusted regression analyses were used to determine the probability of a patient receiving CBC, CT, or pain medication. Use was compared between adults and children. RESULTS: During the course of the study, from 1996 to 2006, the percentage of patients with appendicitis who received a CT scan increased from 6.3% (95% confidence interval [CI] 0% to 15.3%) to 69% (95% CI 55.5% to 81.7%) for adults and from 0% to 59.8% (95% CI 31.6% to 87.9%) for children. CBC use for adults increased from 77.2% (95% CI 62.9% to 91.5%) to 92.8% (95% CI 85.8% to 99.7%) and decreased from 89.1% (95% CI 74.9% to 100.0%) to 68.4% (95% CI 41.9% to 94.9%) for children. The use of pain medications increased from 24.8% (95% CI 11.3% to 38.4%) to 69.9% (95% CI 56.7% to 83.1%) for adults and from 27.2% (95% CI 5.7% to 48.8%) to 42.8% (95% CI 18.1% to 67.5%) for children. The proportion of children who received parenteral narcotics (13.7% [95% CI 9.3% to 18.0%]) was less than that of adults (23% [95% CI 18.9% to 27.1%]). CONCLUSION: CT use has increased for patients with appendicitis over time, and CBC use remains high. There has been an increase in analgesic administration, but more than half of all patients with appendicitis had not received pain medication over the course of the entire study period. Children received fewer parenteral narcotics than adults and appeared to be preferentially treated with nonparenteral nonnarcotic analgesics.

Antenatal Depression and Cesarean Delivery Among Recently-Delivered Nulliparous Women in Rhode Island.

OBJECTIVE: Antenatal depression (AD) is frequently cited as a risk factor for cesarean delivery (CD) with limited supporting data. STUDY DESIGN: We utilized 2016-2018 data from the Pregnancy Risk Assessment Monitoring System (PRAMS) survey for the state of Rhode Island. Nulliparous women who reported AD (n=242) were compared to women who did not (n=1,081). Maternal demographics, pregnancy and delivery characteristics were compared by AD status using population-weighted bivariable analyses and multivariable logistic regression. RESULTS: 17.7% reported AD, and 34% underwent CD. There was no difference in CD based on reported AD status (aOR 1.04; 95% CI 0.69, 1.56). However, there were significant differences between those reporting AD compared to those who did not: less education, more public insurance, use of Women, Infants and Children (WIC) benefits, tobacco use, and pre-gestational hypertension/diabetes. CONCLUSION: In this large, population-based, state representative sample, we found no difference in CD among recently delivered nulliparous women with and without AD.

Prospective Validation of a Rapid Host Gene Expression Test to Discriminate Bacterial From Viral Respiratory Infection.

Importance: Bacterial and viral causes of acute respiratory illness (ARI) are difficult to clinically distinguish, resulting in the inappropriate use of antibacterial therapy. The use of a host gene expression-based test that is able to discriminate bacterial from viral infection in less than 1 hour may improve care and antimicrobial stewardship. Objective: To validate the host response bacterial/viral (HR-B/V) test and assess its ability to accurately differentiate bacterial from viral infection among patients with ARI. Design, Setting, and Participants: This prospective multicenter diagnostic study enrolled 755 children and adults with febrile ARI of 7 or fewer days' duration from 10 US emergency departments. Participants were enrolled from October 3, 2014, to September 1, 2019, followed by additional enrollment of patients with COVID-19 from March 20 to December 3, 2020. Clinical adjudication of enrolled participants identified 616 individuals as having bacterial or viral infection. The primary analysis cohort included 334 participants with high-confidence reference adjudications (based on adjudicator concordance and the presence of an identified pathogen confirmed by microbiological testing). A secondary analysis of the entire cohort of 616 participants included cases with low-confidence reference adjudications (based on adjudicator discordance or the absence of an identified pathogen in microbiological testing). Thirty-three participants with COVID-19 were included post hoc. Interventions: The HR-B/V test quantified the expression of 45 host messenger RNAs in approximately 45 minutes to derive a probability of bacterial infection. Main Outcomes and Measures: Performance characteristics for the HR-B/V test compared with clinical adjudication were reported as either bacterial or viral infection or categorized into 4 likelihood groups (viral very likely [probability score <0.19], viral likely [probability score of 0.19-0.40], bacterial likely [probability score of 0.41-0.73], and bacterial very likely [probability score >0.73]) and compared with procalcitonin measurement. Results: Among 755 enrolled participants, the median age was 26 years (IQR, 16-52 years); 360 participants (47.7%) were female, and 395 (52.3%) were male. A total of 13 participants (1.7%) were American Indian, 13 (1.7%) were Asian, 368 (48.7%) were Black, 131 (17.4%) were Hispanic, 3 (0.4%) were Native Hawaiian or Pacific Islander, 297 (39.3%) were White, and 60 (7.9%) were of unspecified race and/or ethnicity. In the primary analysis involving 334 participants, the HR-B/V test had sensitivity of 89.8% (95% CI, 77.8%-96.2%), specificity of 82.1% (95% CI, 77.4%-86.6%), and a negative predictive value (NPV) of 97.9% (95% CI, 95.3%-99.1%) for bacterial infection. In comparison, the sensitivity of procalcitonin measurement was 28.6% (95% CI, 16.2%-40.9%; P < .001), the specificity was 87.0% (95% CI, 82.7%-90.7%; P = .006), and the NPV was 87.6% (95% CI, 85.5%-89.5%; P < .001). When stratified into likelihood groups, the HR-B/V test had an NPV of 98.9% (95% CI, 96.1%-100%) for bacterial infection in the viral very likely group and a positive predictive value of 63.4% (95% CI, 47.2%-77.9%) for bacterial infection in the bacterial very likely group. The HR-B/V test correctly identified 30 of 33 participants (90.9%) with acute COVID-19 as having a viral infection. Conclusions and Relevance: In this study, the HR-B/V test accurately discriminated bacterial from viral infection among patients with febrile ARI and was superior to procalcitonin measurement. The findings suggest that an accurate point-of-need host response test with high NPV may offer an opportunity to improve antibiotic stewardship and patient outcomes.

Children With ADHD Engage in Less Physical Activity.

Background: Children with ADHD should engage in physical activity, given its known role as a treatment adjunct. Objective: The main objective of this study is to assess the relationship between ADHD diagnosis and physical activity among children in the United States. Methods: This retrospective population-based cross-sectional study used data from the 2016 caregiver reported, National Survey of Children's Health (NSCH). Results: In the adjusted binary model, children with an ADHD diagnosis had 21% lower odds of engaging in daily physical activity than their nondiagnosed counterparts. In the adjusted multinomial model, children with ADHD were increasingly unlikely to report additional days of physical activity as compared to those without a diagnosis. Conclusion: Given the known benefits of physical activity for those with ADHD, this study underscores the need for enhanced access to an important treatment adjunct for this population.

Epidemiology and Clinical Characteristics of Emergency Department Patients with COVID-19 in a Rhode Island Healthcare System.

BACKGROUND: Rhode Island (RI) has been severely impacted by the COVID-19 pandemic. This study aims to describe emergency department (ED) patients with COVID-19 within the largest healthcare system in RI. METHODS: A retrospective electronic medical record review of 1,209 adult patients evaluated and diagnosed with COVID-19 in 4 EDs during the first peak (March 15, 2020 to May 16, 2020) was conducted. Sociodemographic, clinical, management, and ED disposition information were summarized. RESULTS: Median age of patients was 55 years (IQR 40-69), 55.2% were male, and 47.8% were Hispanic/Latinx. Over half of the patients (60.5%) were admitted to the hospital. Supplemental oxygen was used by 32.2%. CONCLUSION: This study presents the clinical and sociodemographic characteristics of ED patients with COVID-19 presenting to the largest healthcare system in Rhode Island. Continued analysis is warranted to provide further insight into the trends in this pandemic.

COVID-19 in Pediatric Patients: Observations from the Initial Phase of the Global Pandemic in Rhode Island.

OBJECTIVE: To describe characteristics of children undergoing SARS-CoV-2 testing during the initial wave of infections in Rhode Island. METHODS: This is a descriptive study of 729 children tested for SARS-CoV-2 at four emergency departments April 9 to May 7, 2020 in Rhode Island. Demographic information and symptoms were cataloged for those tested. RESULTS: 81 (11%) children tested positive for SARS-CoV-2. 94% of positive children were symptomatic. 74% of positive cases had constitutional symptoms and 72% had upper respiratory symptoms. While only 34% of those tested were Hispanic, 68% of the SARS-CoV-2- positive cases occurred in Hispanic children. CONCLUSION: This study details the pediatric population's experience during the first wave of the pandemic in Rhode Island. It could inform testing allocation strategies in healthcare settings. It also highlights vulnerable populations in need of further public health support in our state.