Factors associated with admission to the intensive care unit and mortality in patients with COVID-19, Colombia.

INTRODUCTION: Coronavirus disease 2019 (COVID-19) has affected millions of people worldwide, and several sociodemographic variables, comorbidities and care variables have been associated with complications and mortality. OBJECTIVE: To identify the factors associated with admission to intensive care units (ICUs) and mortality in patients with COVID-19 from 4 clinics in Colombia. METHODS: This was a follow-up study of a cohort of patients diagnosed with COVID-19 between March and August 2020. Sociodemographic, clinical (Charlson comorbidity index and NEWS 2 score) and pharmacological variables were identified. Multivariate analyses were performed to identify variables associated with the risk of admission to the ICU and death (p<0.05). RESULTS: A total of 780 patients were analyzed, with a median age of 57.0 years; 61.2% were male. On admission, 54.9% were classified as severely ill, 65.3% were diagnosed with acute respiratory distress syndrome, 32.4% were admitted to the ICU, and 26.0% died. The factors associated with a greater likelihood of ICU admission were severe pneumonia (OR: 9.86; 95%CI:5.99-16.23), each 1-point increase in the NEWS 2 score (OR:1.09; 95%CI:1.002-1.19), history of ischemic heart disease (OR:3.24; 95%CI:1.16-9.00), and chronic obstructive pulmonary disease (OR:2.07; 95%CI:1.09-3.90). The risk of dying increased in those older than 65 years (OR:3.08; 95%CI:1.66-5.71), in patients with acute renal failure (OR:6.96; 95%CI:4.41-11.78), admitted to the ICU (OR:6.31; 95%CI:3.63-10.95), and for each 1-point increase in the Charlson comorbidity index (OR:1.16; 95%CI:1.002-1.35). CONCLUSIONS: Factors related to increasing the probability of requiring ICU care or dying in patients with COVID-19 were identified, facilitating the development of anticipatory intervention measures that favor comprehensive care and improve patient prognosis.

Telemedicine for Children With Medical Complexity: A Randomized Clinical Trial.

BACKGROUND: Telemedicine is widely used but has uncertain value. We assessed telemedicine to further improve outcomes and reduce costs of comprehensive care (CC) for medically complex children. METHODS: We conducted a single-center randomized clinical trial comparing telemedicine with CC relative to CC alone for medically complex children in reducing care days outside the home (clinic, emergency department, or hospital; primary outcome), rate of children developing serious illnesses (causing death, ICU admission, or hospital stay >7 days), and health system costs. We used intent-to-treat Bayesian analyses with neutral prior assuming no benefit. All participants received CC, which included 24/7 phone access to primary care providers (PCPs), low patient-to-PCP ratio, and hospital consultation from PCPs. The telemedicine group also received remote audiovisual communication with the PCPs. RESULTS: Between August 22, 2018, and March 23, 2020, we randomly assigned 422 medically complex children (209 to CC with telemedicine and 213 to CC alone) before meeting predefined stopping rules. The probability of a reduction with CC with telemedicine versus CC alone was 99% for care days outside the home (12.94 vs 16.94 per child-year; Bayesian rate ratio, 0.80 [95% credible interval, 0.66-0.98]), 95% for rate of children with a serious illness (0.29 vs 0.62 per child-year; rate ratio, 0.68 [0.43-1.07]) and 91% for mean total health system costs (US$33 718 vs US$41 281 per child-year; Bayesian cost ratio, 0.85 [0.67-1.08]). CONCLUSION: The addition of telemedicine to CC likely reduced care days outside the home, serious illnesses, other adverse outcomes, and health care costs for medically complex children.

Changes in Emergency Department Patient Volume and Acuity Associated with Early Stages of the COVID-19 Pandemic in a Unique Environment.

INTRODUCTION: Hospitals and emergency departments (EDs) faced profound uncertainty during the COVID-19 pandemic. Early concerns regarding demand far exceeding capacity were balanced by anecdotal reports of decreased patient visits, including those for specific high-acuity conditions. This study sought to identify changes in ED volume and acuity, within a specific managed care environment, associated with the onset of the pandemic. METHODS: Data from patient visits to 2 San Diego, California, EDs-within an integrated health-care system-were extracted from the electronic health record. Daily patient visits, hospital admissions from the ED, Emergency Severity Index scores, and mode of arrival were compared between two 28-day periods, with the 28 days following a "stay at home" order issued by the governor of California and a control period of the same dates in 2019. RESULTS: These EDs observed a significant decrease in daily visits (42% compared to the previous year) associated with the pandemic. An increased rate of hospital admissions (16.6%-21.6%) was suggestive of an overall increase in acuity; however, changes in the distribution of Emergency Severity Index scores were less pronounced. The overall number of admissions declined significantly. Although overall ambulance traffic decreased, the proportion of patients arriving by ambulance was unchanged. CONCLUSION: Patient volume in 2 EDs dropped significantly in association with a statewide response to the COVID-19 pandemic. There was also a shift in acuity as measured by the proportion of patients admitted to the hospital, but overall admissions declined, suggesting sicker patients also did not seek care.

Nutritional risk is a predictor for long-term mortality: 5-Year follow-up of the EFFORT trial.

BACKGROUND AND AIMS: The nutritional risk screening (NRS 2002) is a validated screening tool for malnutrition. This study aims to investigate the prognostic value of the NRS 2002 and its individual components regarding long-term mortality and adverse outcomes in a well-characterized cohort of medical inpatients. METHODS: We performed a 5-year follow-up investigation of patients included in the investigator-initiated, prospective, randomized controlled multicenter EFFORT trial that evaluated the effects of individualized nutritional intervention vs. standard hospital food. We used multivariable cox regression analyses adjusted for randomisation arm, study centre, comorbidities and main admission diagnosis to investigate associations between NRS 2002 total scores at time of hospital admission and several long-term outcomes. RESULTS: We had confirmed mortality data over the mean follow-up time of 3.2 years in 1874 from the initial cohort of 2028 EFFORT patients. Mortality showed a step-wise increase in patients with NRS 3 (289/565 [51.2%]) and NRS 4 (355/717 [49.6%]) to 59.5% (353/593) in patient with NRS≥5 corresponding to an adjusted Hazard Ratio (HR) of 1.28 (95%CI 1.15 to 1.42, p ≤ 0.001) for mortality after one year and 1.13 (95%CI 1.05 to 1.23, p = 0.002) for the overall time period. All individual components of NRS including disease severity, food intake, weight loss and BMI provided prognostic information regarding long-term mortality risk. CONCLUSION: Nutritional risk mirrored by a NRS 2002 total score is a strong and independent predictor of long-term mortality and morbidity in polymorbid medical inpatients particularly in patients with high nutritional risk with an NRS ≥5 points.

Integrative analysis for COVID-19 patient outcome prediction.

While image analysis of chest computed tomography (CT) for COVID-19 diagnosis has been intensively studied, little work has been performed for image-based patient outcome prediction. Management of high-risk patients with early intervention is a key to lower the fatality rate of COVID-19 pneumonia, as a majority of patients recover naturally. Therefore, an accurate prediction of disease progression with baseline imaging at the time of the initial presentation can help in patient management. In lieu of only size and volume information of pulmonary abnormalities and features through deep learning based image segmentation, here we combine radiomics of lung opacities and non-imaging features from demographic data, vital signs, and laboratory findings to predict need for intensive care unit (ICU) admission. To our knowledge, this is the first study that uses holistic information of a patient including both imaging and non-imaging data for outcome prediction. The proposed methods were thoroughly evaluated on datasets separately collected from three hospitals, one in the United States, one in Iran, and another in Italy, with a total 295 patients with reverse transcription polymerase chain reaction (RT-PCR) assay positive COVID-19 pneumonia. Our experimental results demonstrate that adding non-imaging features can significantly improve the performance of prediction to achieve AUC up to 0.884 and sensitivity as high as 96.1%, which can be valuable to provide clinical decision support in managing COVID-19 patients. Our methods may also be applied to other lung diseases including but not limited to community acquired pneumonia. The source code of our work is available at https://github.com/DIAL-RPI/COVID19-ICUPrediction.

Severe acute malnutrition in children admitted in an Intensive Therapeutic and Feeding Centre of South Kivu, Eastern Democratic Republic of Congo: Why do our patients die?

BACKGROUND: Severe acute malnutrition (SAM) remains a serious public health concern in low- and middle-income countries. Little is known about treatment outcomes of child inpatients in Intensive Therapeutic and Feeding Units. This study aimed to assess treatment outcomes of SAM and identify factors associated with mortality among children treated at Saint Joseph Nutritional Center, South Kivu, Eastern Democratic Republic of Congo. METHODS: A retrospective hospital-based cross-sectional study was conducted on medical records of 633 severely malnourished children followed as inpatients at Saint Joseph Nutritional Center from July 2017 to December 2018. Data were entered, thoroughly cleaned and analyzed in SPSS version 25. Univariable and multivariable logistic regression model were fitted to identify factors associated with mortality. RESULTS: Among 633 patients admitted with SAM, 13.1% were lost to follow-up and 9.2% died while in hospital. Children with late referral to the health facility (> 14 days) after the onset of main external malnutrition signs had 2.03 times higher odds of death than those referred less than 14 days [AOR = 2.03 at 95%CI (1.12, 3.68)]. The odds of death was 1.91 times higher for children with MUAC < 115 mm than for those with MUAC ≥ 115 mm [AOR = 1.91 at 95% CI (1.05, 3.50)]. Children infected with HIV were 3.90 times more likely to die compared to their counterparts [AOR = 3.90 at 95% CI (2.80, 9.41)]. CONCLUSION: Particular emphasis should be placed on partnering with communities to improve information on malnutrition signs and on critical importance of early referral to the health system. While HIV incidence in DRC is still low (0.21%), its impact on mortality among severely malnourished children is increased due to the limited access to HIV testing and antiretroviral therapy.

Active surveillance of acute paediatric hospitalisations demonstrates the impact of vaccination programmes and informs vaccine policy in Canada and Australia.

Sentinel surveillance of acute hospitalisations in response to infectious disease emergencies such as the 2009 influenza A(H1N1)pdm09 pandemic is well described, but recognition of its potential to supplement routine public health surveillance and provide scalability for emergency responses has been limited. We summarise the achievements of two national paediatric hospital surveillance networks relevant to vaccine programmes and emerging infectious diseases in Canada (Canadian Immunization Monitoring Program Active; IMPACT from 1991) and Australia (Paediatric Active Enhanced Disease Surveillance; PAEDS from 2007) and discuss opportunities and challenges in applying their model to other contexts. Both networks were established to enhance capacity to measure vaccine preventable disease burden, vaccine programme impact, and safety, with their scope occasionally being increased with emerging infectious diseases' surveillance. Their active surveillance has increased data accuracy and utility for syndromic conditions (e.g. encephalitis), pathogen-specific diseases (e.g. pertussis, rotavirus, influenza), and adverse events following immunisation (e.g. febrile seizure), enabled correlation of biological specimens with clinical context and supported responses to emerging infections (e.g. pandemic influenza, parechovirus, COVID-19). The demonstrated long-term value of continuous, rather than incident-related, operation of these networks in strengthening routine surveillance, bridging research gaps, and providing scalable public health response, supports their applicability to other countries.

Trends in Neonatal Intensive Care Unit Utilization in a Large Integrated Health Care System.

Importance: There are few population-based studies addressing trends in neonatal intensive care unit (NICU) admission and NICU patient-days, especially in the subpopulation that, by gestational age (GA) and birth weight (BW), might otherwise be able to stay in the room with their mothers. Objective: To describe population-based trends in NICU admissions, NICU patient-days, readmissions, and mortality in the birth population of a large integrated health care system. Design, Setting, and Participants: This cohort study was conducted using data extracted from electronic medical records at Kaiser Permanente Southern California (KPSC) health care system. Participants included all women who gave birth at KPSC hospitals and their newborns from January 1, 2010, through December 31, 2018. Data extraction was limited to data entry fields whose contents were either numbers or fixed categorical choices. Rates of NICU admission, NICU patient-days, readmission rates, and mortality rates were measured in the total population, in newborns with GA 35 weeks or greater and BW 2000 g or more (high GA and BW group), and in the remaining newborns (low GA and BW group). Admissions to the NICU and NICU patient-days were risk adjusted with a machine learning model based on demographic and clinical characteristics before NICU admission. Changes in the trends were assessed with 2-sided correlated seasonal Mann-Kendall test. Data analysis was performed in August 2019. Exposures: Admission to the NICU and NICU patient-days among the birth cohort. Main Outcomes and Measures: The primary outcomes were NICU admission and NICU patient-days in the total neonatal population and GA and BW subgroups. The secondary outcomes were readmission and mortality rates. Results: Over the study period there were 320 340 births (mean [SD] age of mothers, 30.1 [5.7] years; mean [SD] gestational age, 38.6 [1.97] weeks; mean [SD] birth weight, 3302 [573] g). The risk-adjusted NICU admission rate decreased from a mean of 14.5% (95% CI, 14.2%-14.7%) to 10.9% (95% CI, 10.7%-11.7%) (P for trend = .002); 92% of the change was associated with changes in the care of newborns in the high GA and BW group. The number of risk-adjusted NICU patient-days per birth decreased from a mean of 1.50 patient-days (95% CI, 1.43-1.54 patient-days) to 1.40 patient-days (95% CI, 1.36-1.48 patient-days) (P for trend = .03); 70% of the change was associated with newborns in the high GA and BW group. The unadjusted 30-day readmission rates and mortality rates did not change. Conclusions and Relevance: Admission rates to the NICU and numbers of NICU patient-days decreased over the study period without an increase in readmissions or mortality. The observed decrease was associated with the high GA and BW newborn population. How much of this decrease is attributable to intercurrent health care systemwide quality improvement initiatives would require further investigation. The remaining unexplained variation suggests that further changes are also possible.

Nutritional status according to the mini nutritional assessment (MNA)® as potential prognostic factor for health and treatment outcomes in patients with cancer - a systematic review.

BACKGROUND: Patients with cancer have an increased risk of malnutrition which is associated with poor outcome. The Mini Nutritional Assessment (MNA®) is often used in older patients with cancer but its relation to outcome is not known. METHODS: Four databases were systematically searched for studies relating MNA-results with any reported outcome. Two reviewers screened titles/abstracts and full-texts, extracted data and rated the risk of bias (RoB) independently. RESULTS: We included 56 studies which varied widely in patient and study characteristics. In multivariable analyses, (risk of) malnutrition assessed by MNA significantly predicts a higher chance for mortality/poor overall survival (22/27 studies), shorter progression-free survival/time to progression (3/5 studies), treatment maintenance (5/8 studies) and (health-related) quality of life (2/2 studies), but not treatment toxicity/complications (1/7 studies) or functional status/decline in (1/3 studies). For other outcomes - length of hospital stay (2 studies), falls, fatigue and unplanned (hospital) admissions (1 study each) - no adjusted results were reported. RoB was rated as moderate to high. CONCLUSIONS: MNA®-result predicts mortality/survival, cancer progression, treatment maintenance and (health-related) quality of life and did not predict adverse treatment outcomes and functional status/ decline in patients with cancer. For other outcomes results are less clear. The moderate to high RoB calls for studies with better control of potential confounders.

Respiratory illness, hospital visits, and health costs: Is it air pollution or pollen?

BACKGROUND: Both air pollution and airborne pollen can cause respiratory health problems. Since both are often jointly present in ambient air, it is important to control for one while estimating the effect of the other when considering pollution-abating policies. To date only a limited number of studies have considered the health effects of both irritants jointly for a general population, and for a sufficiently long time period to allow for variation in seasonal concentrations of both components. The primary goal of this study is to determine the causal impact of fine particulate matter (PM2.5) on hospital visits and related treatment costs, while controlling for potentially confounding pollen effects. Our study area is the metropolitan hub of Reno/Sparks in Northern Nevada. METHODS: Taking advantage of a rare sample of daily pollen counts over a prolonged period of time (2009-2015), we model the effects of PM2.5 and pollen on respiratory-related hospital admissions for the population at large, plus specific age groups. Pollen data are provided by a local allergy clinic. Data on PM2.5 and other air pollutants are obtained from the U.S. Environmental Protection Agency's air quality data web site. We collect daily meteorological data from the National Centers for Environmental Information's data repository. Data on hospital admissions are given by the Nevada Center for Surveys, Evaluations, and Statistics. Our econometric approach centers on a fully robust count data (Poisson) model, estimated via Quasi-Maximum Likelihood. RESULTS: We find that for our sample PM2.5 effects are largely robust to the inclusion of both pollen counts and temporal indicators. In contrast, pollen effects vanish when time fixed effects are added, pointing at their correlation with unobserved temporal confounders. At the same time, model fit improves with the inclusion of temporal indicators. Based on our preferred specification, we find a significant PM2.5 effect of approximately 0.5% additional hospital visits per day due to a one µg/m3 increase in PM2.5. This translates into expected augmented treatment costs of $2700 per day for the same unit-change in PM2.5. These figures can mount quickly when more pronounced and/or longer episodes of particulate matter pollution are considered, perhaps due to wildfire smoke. For instance, the expected increase in patients and costs due to a month-long 10-unit-jump of PM2.5 over the long-run annual average would amount to an extra 70 patients and approximately $680,000 in additional treatment costs.

Plasma 25-Hydroxyvitamin D Level at Admission Predicts Unfavorable Outcome in Intensive Care Unit Patients.

INTRODUCTION: Patients in intensive care units (ICUs) are at high risk of unfavorable outcomes. Considering the role of vitamin D (Vit D) in cardiovascular and immune functions, Vit D deficiency could affect ICU patients' outcomes. This study aimed to evaluate Vit D status and its predictive value for outcome in ICU patients. PATIENTS AND METHODS: A total of 169 ICU patients were followed during ICU stay. Primary outcome was the occurrence of at least one major adverse event; secondary outcomes were organ failure, septic shock, ICU-acquired infection, other adverse events, and ICU mortality. Plasma 25-hydroxyvitamin D (25(OH)D) was assessed by immunoassay. Multivariate Cox regression analyses were performed to test the associations of low 25(OH)D levels with poor outcomes. RESULTS: Around 75% of patients had 25(OH)D levels <12 ng/ml. During their ICU stay, 114 patients experienced a major adverse event, 85 patients presented an ICU-acquired infection, and 22 patients died. Plasma 25(OH)D levels <12 ng/ml were associated with higher risk of major adverse events, Hazard ratio [95% CI], 4.47 [1.77, 11.3], p = .020, and ICU-acquired infection, 2.67 [1.01, 7.42], p = .049, but not with increased risk of ICU mortality. CONCLUSIONS: Hypovitaminosis D is very common in ICU patients. Results of the present study show that low plasma 25(OH)D levels are associated with increased risk of unfavorable outcomes in these patients. Additional research is needed to investigate the impact of Vit D status and effect of Vit D supplementation in ICU patients.

Proportionate Postnatal Growth in Preterm Neonates on Expressed Breast Milk Feeding With Selected Fortification.

BACKGROUND: Preterm neonates not fed an exclusive human-milk diet in the neonatal intensive care unit (NICU) show disproportionate postnatal growth. There are scant data on postnatal growth in neonates from India fed an exclusive expressed breast milk (EBM) diet. This study describes the postnatal changes in weight, length, and head circumference in preterm neonates given EBM with selected fortification. METHODS: The study had a prospective observational design. Exclusive EBM feeding, early initiation, and standardized progression of feeds was followed. Fortification of breast milk with human milk fortifier (HMF) or liquid calcium phosphate and multivitamins (CALVIT) or hindmilk (HM) was done based on the gestational age. Monitoring for weight, length, and head circumference was done from admission to discharge. RESULTS: Ninety-three preterm neonates were included in the study, of which 34 (36.6%) were small for gestational age. Thirty-two (34.3%) neonates received EBM with HMF, 35 (35.7%) received EBM fortified with CALVIT and 26 (28%) neonates received HM fortification. There was a significant difference in the change in z-scores from birth to discharge for the weight, length, and head circumference (P = .001). The mean increase in daily weight ranged from 8.8 to 9.5 g/d, whereas weekly change in length was 0.8-0.9 cm/wk, and head circumference was 0.7 cm/wk. CONCLUSION: Postnatal growth of preterm neonates during NICU admission on exclusive EBM feeding with selected fortification resulted in a proportionate increase in weight, length, and head circumference.

Vitamin A and iron status of children before and after treatment of uncomplicated severe acute malnutrition.

BACKGROUND & AIMS: Treatment of children with uncomplicated severe acute malnutrition (SAM) is based on ready-to-use therapeutic foods (RUTF) and aims for quick regain of lost body tissues while providing sufficient micronutrients to restore diminished body stores. Little evidence exists on the success of the treatment to establish normal micronutrient status. We aimed to assess the changes in vitamin A and iron status of children treated for SAM with RUTF, and explore the effect of a reduced RUTF dose. METHODS: We collected blood samples from children 6-59 months old with SAM included in a randomised trial at admission to and discharge from treatment and analysed haemoglobin (Hb) and serum concentrations of retinol binding protein (RBP), ferritin (SF), soluble transferrin receptor (sTfR), C-reactive protein (CRP) and α1-acid glycoprotein (AGP). SF, sTfR and RBP were adjusted for inflammation (CRP and AGP) prior to analysis using internal regression coefficients. Vitamin A deficiency (VAD) was defined as RBP < 0.7 µmol/l, anaemia as Hb < 110 g/l, storage iron deficiency (sID) as SF < 12 µg/l, tissue iron deficiency (tID) as sTfR > 8.3 mg/l and iron deficiency anaemia (IDA) as both anaemia and sID. Linear and logistic mixed models were fitted including research team and study site as random effects and adjusting for sex, age and outcome at admission. RESULTS: Children included in the study (n = 801) were on average 13 months of age at admission to treatment and the median treatment duration was 56 days [IQR: 35; 91] in both arms. Vitamin A and iron status markers did not differ between trial arms at admission or at discharge. Only Hb was 1.7 g/l lower (95% CI -0.3, 3.7; p = 0.088) in the reduced dose arm compared to the standard dose, at recovery. Mean concentrations of all biomarkers improved from admission to discharge: Hb increased by 12% or 11.6 g/l (95% CI 10.2, 13.0), RBP increased by 13% or 0.12 µmol/l (95% CI 0.09, 0.15), SF increased by 36% or 4.4 µg/l (95% CI 3.1, 5.7) and sTfR decreased by 16% or 1.5 mg/l (95% CI 1.0, 1.9). However, at discharge, micronutrient deficiencies were still common, as 9% had VAD, 55% had anaemia, 35% had sID, 41% had tID and 21% had IDA. CONCLUSION: Reduced dose of RUTF did not result in poorer vitamin A and iron status of children. Only haemoglobin seemed slightly lower at recovery among children treated with the reduced dose. While improvement was observed, the vitamin A and iron status remained sub-optimal among children treated successfully for SAM with RUTF. There is a need to reconsider RUTF fortification levels or test other potential strategies in order to fully restore the micronutrient status of children treated for SAM.

Grass pollen as a trigger of emergency department presentations and hospital admissions for respiratory conditions in the subtropics: A systematic review.

INTRODUCTION: It is unknown if high concentration of airborne grass pollen, where subtropical grasses (Chloridoideae and Panicoideae) dominate, is a risk factor for respiratory health. Here we systematically reviewed the association between airborne grass pollen exposure and asthma emergency department (ED) presentations and hospital admissions in subtropical climates. OBJECTIVES: A systematic review was performed to identify and summarise studies that reported on respiratory health (asthma ED presentations and hospital admissions) and airborne grass pollen exposure in subtropical climates. METHODS: Searches were conducted in: MEDLINE, Web of Science, Scopus, CINAHL (EBSCO), Embase and Google Scholar databases (1966-2019). Risk of bias was assessed using a validated quality assessment tool. A meta-analysis was planned, however due to the heterogeneity in study design it was determined inappropriate and instead a narrative synthesis was undertaken. RESULTS: Nineteen studies were identified for inclusion, with a total of 598,931 asthma ED presentation participants and 36,504 asthma hospital admission participants in six countries (Australia, India, Israel, Italy, Spain, USA). The narrative synthesis found airborne grass pollen appears to have a small and inconsistent increase on asthma ED presentations (judged as: probably little effect n = 5, may have little effect n = 4, no effect n = 2 and uncertain if there is an effect n = 4) and hospital admissions (judged as: probably increase slightly n = 2 probably little effect n = 1, may have a little effect n = 1, no effect n = 3 and we are uncertain if there is an effect n = 4) in the subtropics. Furthermore, the reported effect sizes were small and its clinical relevance may be difficult to discern. CONCLUSION: Exposure to airborne grass pollen appears to have a small and inconsistent increase on asthma ED presentations and hospital admissions in the subtropics. These findings are comparable to reported observations from studies undertaken in temperate regions.

Evaluation of Home Phototherapy for Neonatal Hyperbilirubinemia.

OBJECTIVE: To characterize home phototherapy treatment for neonatal hyperbilirubinemia and assess the risk factors associated with the need for hospital admission during or after home phototherapy. STUDY DESIGN: This was a retrospective study of newborn infants born at ≥35 weeks of gestation who underwent comprehensive home phototherapy (that included daily in-home lactation support and blood draws) over an 18-month period. We excluded infants who lacked a recorded birth date or time, started treatment at age >14 days, or had a conjugated serum bilirubin level of ≥2 mg/dL (≥34.2 µmol/L). The primary study outcome was any hospital admission during or within 24 hours after completion of home phototherapy. Logistic regression was used to identify risk factors for hospitalization. RESULTS: Of the cohort of 1385 infants, 1324 met the inclusion criteria. At the time home phototherapy was initiated, 376 infants (28%) were at or above the American Academy of Pediatrics phototherapy threshold. Twenty-five infants required hospitalization (1.9%; 95% CI, 1.3%-2.8%). Hospital admission was associated with a younger age at phototherapy initiation (OR, 0.63 for each day older in age; 95% CI, 0.44-0.91) and a higher total serum bilirubin level relative to the treatment threshold at phototherapy initiation (OR, 1.71 for each 1 mg/dL above the treatment threshold; 95% CI, 1.40-2.08). CONCLUSIONS: Comprehensive home phototherapy successfully treated hyperbilirubinemia in the vast majority of the infants in this cohort.

Effect of a Virtual Patient Navigation Program on Behavioral Health Admissions in the Emergency Department: A Randomized Clinical Trial.

IMPORTANCE: The number of patients presenting to emergency departments (EDs) for psychiatric care continues to increase. Psychiatrists often make a conservative recommendation to admit patients because robust outpatient services for close follow-up are lacking. OBJECTIVE: To assess whether the availability of a 45-day behavioral health-virtual patient navigation program decreases hospitalization among patients presenting to the ED with a behavioral health crisis or need. DESIGN, SETTING, AND PARTICIPANTS: This randomized clinical trial enrolled 637 patients who presented to 6 EDs spanning urban and suburban locations within a large integrated health care system in North Carolina from June 12, 2017, through February 14, 2018; patients were followed up for up to 45 days. Eligible patients were aged 18 years or older, with a behavioral health crisis and a completed telepsychiatric ED consultation. The availability of the behavioral health-virtual patient navigation intervention was randomly allocated to specific days (Monday through Friday from 7 am to 7 pm) so that, in a 2-week block, there were 5 intervention days and 5 usual care days; 323 patients presented on days when the program was offered, and 314 presented on usual care days. Data analysis was performed from March 7 through June 13, 2018, using an intention-to-treat approach. INTERVENTIONS: The behavioral health-virtual patient navigation program included video contact with a patient while in the ED and telephonic outreach 24 to 72 hours after discharge and then at least weekly for up to 45 days. MAIN OUTCOMES AND MEASURES: The primary outcome was the conversion of an ED encounter to hospital admission. Secondary outcomes included 45-day follow-up encounters with a self-harm diagnosis and postdischarge acute care use. RESULTS: Among 637 participants, 358 (56.2%) were men, and the mean (SD) age was 39.7 (16.6) years. The conversion rates were 55.1% (178 of 323) in the intervention group vs 63.1% (198 of 314) in the usual care group (odds ratio, 0.74; 95% CI, 0.54-1.02; P = .06). The percentage of patient encounters with follow-up encounters having a self-harm diagnosis was significantly lower in the intervention group compared with the usual care group (36.8% [119 of 323] vs 45.5% [143 of 314]; P = .03). CONCLUSIONS AND RELEVANCE: Although the primary result did not reach statistical significance, there is a strong signal of potential positive benefit in an area that lacks evidence, suggesting that there should be additional investment and inquiry into virtual behavioral health programs. TRIAL REGISTRATION: ClinicalTrials.gov identifier: NCT03204643.

Admitting women in active labour: A randomised controlled trial about the effects of protocol use on childbirth method and interventions.

AIM: To determine the effects of protocol of admitting women in active labour on childbirth method and interventions during labour and childbirth. METHODS: This single-blind randomised clinical trial was conducted in a public hospital in Mazandaran province (Iran) in 2017. Two hundred nulliparous low-risk women were randomly assigned into intervention and control groups. The participant women were admitted in the intervention group using the admission protocol and to the group control by staff midwives and doctors. The admission criteria of the protocol were: the presence of regular, painful contractions, the cervix at least four cm dilated and at least one of the following cues: cervix effaced, and spontaneous rupture of membranes, or "show". The primary outcome measure was childbirth method. Data were analyzed in SPSS-22 using Mann-Whitney and Chi-square tests. The level of statistical significance was set as p<0.05. FINDING: There were significant differences between the intervention and control groups in the number of caesarian section (CS) (p<0.001). Two groups had a statistically significant difference in amniotomy (p=0.003), augmentation by oxytocin (p<0.001), number of vaginal examinations (p<0.001) and fundal pressure (p<0.001). CONCLUSIONS: Using a protocol for admission of low risk nulliparous women in active labour contributed to reduction of the primary caesarean section rate and interventions during childbirth. A risk assessment and using evidence informed guidelines in admission can contribute to reduce unsafe and harmful practices and support normalisation of birth. This is essential for demedicalisation and a useful strategy for reducing primary CS.

Attendance at National Cancer Institute and Children's Oncology Group Facilities for Children, Adolescents, and Young Adults with Cancer in Pennsylvania: A Population-Based Study.

Purpose: Adolescents and young adults (AYAs) with cancer are a vulnerable population with decreased attendance at National Cancer Institute (NCI) comprehensive cancer centers and Children's Oncology Group (COG) facilities. Decreased attendance at NCI/COG facilities has been associated with poor cancer outcomes. The objective of this study was to evaluate cancer care patterns of AYAs compared with children, within Pennsylvania, and factors associated with attending an NCI/COG facility. Methods: Data from the Pennsylvania Cancer Registry between 2010 and 2015 for patients aged 0-39 years at cancer diagnosis were used. Primary analyses focused on age at diagnosis, insurance status, race, ethnicity, gender, cancer type, stage, diagnosis year, and distance to the NCI/COG facility. The primary outcome was receipt of care at an NCI/COG facility. Odds ratios (ORs) were calculated using multivariable logistic regression models. Sensitivity analyses were conducted to test and estimate robustness. Results: A sample of 15,002 patients, ages 0-39, was obtained, including 8857 patients (59%) who attended an NCI/COG facility. Patients were significantly less likely to attend an NCI/COG facility if they were aged 31-39 years (OR 0.054, 95% confidence interval [CI] 0.04-0.07), non-White (OR 0.890, 95% CI 0.80-0.99), Hispanic (OR 0.701, 95% CI 0.59-0.83), female (OR 0.915, 95% CI 0.84-1.00), had Medicaid insurance (OR 0.836, 95% CI 0.75-0.93), and lived further from an NCI/COG facility. Sensitivity analyses largely corroborated the performed estimates. Conclusions: AYAs with cancer in Pennsylvania have disproportionate attendance at specialized NCI/COG facilities across a variety of demographic domains. Enhancing the attendance of AYAs with cancer at these specialized centers is crucial to improve cancer outcomes.

Reasons for Interfacility Emergency Department Transfer and Care at the Receiving Facility.

OBJECTIVES: The aims of this study were to (1) assess the reasons for pediatric interfacility transfers as identified by transferring providers and review the emergency medical care delivered at the receiving facilities and (2) investigate the emergency department (ED) care among the subpopulation of patients discharged from the receiving facility. METHODS: We performed a multicenter, cross-sectional survey of ED medical providers transferring patients younger than 18 years to 1 of 4 US tertiary care pediatric hospitals with a subsequent medical record review at the receiving facility. Referring providers completed surveys detailing reasons for transfer. RESULTS: Eight hundred thirty-nine surveys were completed by 641 providers for 25 months. The median patient age was 5.7 years. Sixty-two percent of the patients required admission. The most common reasons for transfer as cited by referring providers were subspecialist consultation (62%) and admission to a pediatric inpatient (17%) or intensive care (6%) unit. For discharged patients, plain radiography (26%) and ultrasonography (12%) were the most common radiologic studies. Procedural sedation (16%) was the most common ED procedure for discharged patients, and 55% had a subspecialist consult at the receiving facility. Ten percent of interfacility transfers did not require subspecialty consult, ED procedure, radiologic study, or admission. CONCLUSIONS: Approximately 4 of 10 interfacility transfers are discharged by the receiving facility, suggesting an opportunity to provide more comprehensive care at referring facilities. On the basis of the care provided at the receiving facility, potential interventions might include increased subspecialty access and developing both ultrasound and sedation capabilities.

Reducing Albuterol Use in Children With Bronchiolitis.

OBJECTIVES: In 2014, the American Academy of Pediatrics published bronchiolitis guidelines recommending against the use of bronchodilators. For the winter of 2015 to 2016, we aimed to reduce the proportion of emergency department patients with bronchiolitis receiving albuterol from 43% (previous winter rate) to <35% and from 18% (previous winter rate) to <10% in the inpatient setting. METHODS: A team identified key drivers of albuterol use and potential interventions. We implemented changes to our pathway and the associated order set recommending against routine albuterol use and designed education to accompany the pathway changes. We monitored albuterol use through weekly automated data extraction and reported results back to clinicians. We measured admission rate, length of stay, and revisit rate as balancing measures for the intervention. RESULTS: The study period included 3834 emergency department visits and 1119 inpatient hospitalizations. In the emergency department, albuterol use in children with bronchiolitis declined from 43% to 20% and was <3 SD control limits established in the previous year, meeting statistical thresholds for special cause variation. Inpatient albuterol use decreased from 18% to 11% of patients, also achieving special cause variation and approaching our goal. The changes in both departments were sustained through the entire bronchiolitis season, and admission rate, length of stay, and revisit rates remained unchanged. CONCLUSIONS: Using a multidisciplinary group that redesigned a clinical pathway and order sets for bronchiolitis, we substantially reduced albuterol use at a large children's hospital without impacting other outcome measures.