Tobacco Smoke Exposure and Sleep Duration among U.S. Adolescents.

OBJECTIVES: Tobacco smoke exposure (TSE) and poor sleep are public health problems with their own set of consequences. This study assessed whether TSE was associated with sleep duration among U.S. adolescents. METHOD: We conducted a secondary analysis of 2013-2018 National Health and Nutrition Examination Survey data including 914 nontobacco-using adolescents ages 16-19 years. TSE measures included cotinine and self-reported home TSE groups including no home TSE, thirdhand smoke (THS) exposure, and secondhand smoke (SHS)+THS exposure. Sleep duration was assessed in hours and categorically as insufficient sleep (recommended hours). Weighted multiple linear regression and multinomial regression models were conducted. RESULTS: Adolescents with higher log-cotinine levels had higher number of sleep hours (ß = 0.31, 95%CI = 0.02,0.60) and were at increased odds of reporting excess sleep (AOR = 1.41, 95%CI = 1.40,1.42), but were at reduced odds of reporting insufficient sleep (AOR = 0.88, 95%CI = 0.87,0.89). Compared to adolescents with no home TSE, adolescents with home THS exposure and home SHS+THS exposure were at increased odds of reporting insufficient sleep (AOR = 2.27, 95%CI = 2.26,2.29; AOR = 2.75, 95%CI = 2.72,2.77, respectively) and excess sleep (AOR = 1.89, 95%CI = 1.87,1.90; AOR = 5.29, 95%CI = 5.23,5.34, respectively). CONCLUSIONS: TSE may affect insufficient and excess sleep duration among adolescents. Eliminating TSE may promote adolescent respiratory and sleep health.

Contamination of surfaces in children's homes with nicotine and the potent carcinogenic tobacco-specific nitrosamine NNK.

BACKGROUND: Tobacco smoke exposure (TSE) through secondhand and thirdhand smoke is a modifiable risk factor that contributes to childhood morbidity. Limited research has assessed surface TSE pollution in children's environments as a potential source of thirdhand smoke exposure, and none have examined levels of the tobacco-specific nitrosamine 4-(methylnitrosamino)-1-(3-pyridyl)-1-butanone (NNK) on surfaces. OBJECTIVE: This study measured surface NNK and nicotine in children's homes and associations with sociodemographics and parent-reported TSE behaviors. We assessed correlations of surface NNK and nicotine with dust NNK, dust nicotine, and child cotinine. METHODS: Home surface wipe NNK and nicotine data from 84 children who lived with smokers were analyzed. Tobit and simple linear regression analyses were conducted to assess associations of surface NNK and nicotine with child characteristics. Spearman's (ρ) correlations assessed the strength of associations between environmental markers and child cotinine. RESULTS: Nearly half (48.8%) of children's home surfaces had detectable NNK and 100% had detectable nicotine. The respective geometric means (GMs) of surface NNK and nicotine loadings were 14.0 ng/m2 and 16.4 µg/m2. Surface NNK positively correlated with surface nicotine (ρ = 0.54, p < 0.001) and dust NNK (ρ = 0.30, p = 0.020). Surface nicotine positively correlated with dust NNK (ρ = 0.42, p < 0.001) and dust nicotine (ρ = 0.24, p = 0.041). Children with household incomes ≤$15,000 had higher surface NNK levels (GM = 18.7 ng/m2, p = 0.017) compared to children with household incomes >$15,000 (GM = 7.1 ng/m2). Children with no home smoking bans had higher surface NNK (GM = 18.1 ng/m2, p = 0.020) and surface nicotine (GM = 17.7 µg/m2, p = 0.019) levels compared to children with smoking bans (GM = 7.5 ng/m2, 4.8 µg/m2, respectively). IMPACT: Although nicotine on surfaces is an established marker of thirdhand smoke pollution, other thirdhand smoke contaminants have not been measured on surfaces in the homes of children living with smokers. We provide evidence that the potent carcinogenic tobacco-specific nitrosamine NNK was detectable on surfaces in nearly half of children's homes, and nicotine was detectable on all surfaces. Surface NNK was positively correlated with surface nicotine and dust NNK. Detectable surface NNK levels were found in homes with indoor smoking bans, indicating the role of NNK as a persistent thirdhand smoke pollutant accumulating on surfaces as well as in dust.

The Associations of Trans-3'-Hydroxy Cotinine, Cotinine, and the Nicotine Metabolite Ratio in Pediatric Patients with Tobacco Smoke Exposure.

(1) Background: Trans-3'-hydroxy cotinine (3HC) and cotinine (COT) are tobacco smoke exposure (TSE) biomarkers and the 3HC/COT ratio is a marker of CYP2A6 activity, an enzyme which metabolizes nicotine. The primary objective was to assess the associations of these TSE biomarkers with sociodemographics and TSE patterns in children who lived with ≥1 smoker. (2) Methods: A convenience sample of 288 children (mean age (SD) = 6.42 (4.8) years) was recruited. Multiple linear regression models were built to assess associations of sociodemographics and TSE patterns with urinary biomarker response variables: (1) 3HC, (2) COT, (3) 3HC+COT sum, and (4) 3HC/COT ratio. (3) Results: All children had detectable 3HC (Geometric Mean [GeoM] = 32.03 ng/mL, 95%CI = 26.97, 38.04) and COT (GeoM = 10.24 ng/mL, 95%CI = 8.82, 11.89). Children with higher cumulative TSE had higher 3HC and COT (ß^ = 0.03, 95%CI = 0.01, 0.06, p = 0.015 and ß^ = 0.03, 95%CI = 0.01, 0.05, p = 0.013, respectively). Highest 3HC+COT sum levels were in children who were Black (ß^ = 0.60, 95%CI = 0.04, 1.17, p = 0.039) and who had higher cumulative TSE (ß^ = 0.03, 95%CI = 0.01, 0.06, p = 0.015). Lowest 3HC/COT ratios were in children who were Black (ß^ = -0.42, 95%CI = -0.78, -0.07, p = 0.021) and female (ß^ = -0.32, 95%CI = -0.62, -0.01, p = 0.044). (4) Conclusion: Results indicate that there are racial and age-related differences in TSE, most likely due to slower nicotine metabolism in non-Hispanic Black children and in younger children.

Complex Morphologic Analysis of Cerebral Aneurysms Through the Novel Use of Fractal Dimension as a Predictor of Rupture Status: A Proof of Concept Study.

BACKGROUND: Aneurysm morphology has been correlated with rupture. Previous reports identified several morphologic indices that predict rupture status, but they measure only specific qualities of the morphology of an aneurysm in a semiquantitative fashion. Fractal analysis is a geometric technique whereby the overall complexity of a shape is quantified through the calculation of a fractal dimension (FD). By progressively altering the scale of measurement of a shape and determining the number of segments required to incorporate the entire shape, a noninteger value for the dimension of the shape is derived. We present a proof-of-concept study to calculate the FD of an aneurysm for a small cohort of patients with aneurysms in 2 specific locations to determine whether FD is associated with aneurysm rupture status. METHODS: Twenty-nine aneurysms of the posterior communicating and middle cerebral arteries were segmented from computed tomography angiograms in 29 patients. FD was calculated using a standard box-counting algorithm extended for use with three-dimensional shapes. Nonsphericity index and undulation index (UI) were used to validate the data against previously reported parameters associated with rupture status. RESULTS: Nineteen ruptured and 10 unruptured aneurysms were analyzed. Through logistic regression analysis, lower FD was found to be significantly associated with rupture status (P = 0.035; odds ratio, 0.64; 95% confidence interval, 0.42-0.97 per FD increment of 0.05). CONCLUSIONS: In this proof-of-concept study, we present a novel approach to quantify the geometric complexity of intracranial aneurysms through FD. These data suggest an association between FD and patient-specific aneurysm rupture status.

Distinguishing Exposure to Secondhand and Thirdhand Tobacco Smoke among U.S. Children Using Machine Learning: NHANES 2013-2016.

While the thirdhand smoke (THS) residue from tobacco smoke has been recognized as a distinct public health hazard, there are currently no gold standard biomarkers to differentiate THS from secondhand smoke (SHS) exposure. This study used machine learning algorithms to assess which combinations of biomarkers and reported tobacco smoke exposure measures best differentiate children into three groups: no/minimal tobacco smoke exposure (NEG); predominant THS exposure (TEG); and mixed SHS and THS exposure (MEG). Participants were 4485 nonsmoking 3-17-year-olds from the National Health and Nutrition Examination Survey 2013-2016. We fitted and tested random forest models, and the majority (76%) of children were classified in NEG, 16% were classified in TEG, and 8% were classified in MEG. The final classification model based on reported exposure, biomarker, and biomarker ratio variables had a prediction accuracy of 95%. This final model had prediction accuracies of 100% for NEG, 88% for TEG, followed by 71% for MEG. The most important predictors were the reported number of household smokers, serum cotinine, serum hydroxycotinine, and urinary 4-(methylnitrosamino)-1-(3-pyridyl)-1-butanol (NNAL). In the absence of validated biomarkers specific to THS, comprehensive biomarker and questionnaire data for tobacco smoke exposure can distinguish children exposed to SHS and THS with high accuracy.

Sources of Tobacco Smoke Exposure and Their Associations With Serum Cotinine Levels Among US Children and Adolescents.

INTRODUCTION: We assessed tobacco smoke exposure (TSE) levels based on private and public locations of TSE according to race and ethnicity among US school-aged children ages 6-11 years and adolescents ages 12-17 years. AIMS AND METHODS: Data were from 5296 children and adolescents who participated in the National Health and Nutrition Examination Survey (NHANES) 2013-2018. Racial and ethnic groups were non-Hispanic white, black, other or multiracial, and Hispanic. NHANES assessed serum cotinine and the following TSE locations: homes and whether smokers did not smoke indoors (home thirdhand smoke [THS] exposure proxy) or smoked indoors (secondhand [SHS] and THS exposure proxy), cars, in other homes, restaurants, or any other indoor area. We used stratified weighted linear regression models by racial and ethnic groups and assessed the variance in cotinine levels explained by each location within each age group. RESULTS: Among 6-11-year-olds, exposure to home THS only and home SHS + THS predicted higher log-cotinine among all racial and ethnic groups. Non-Hispanic white children exposed to car TSE had higher log-cotinine (ß = 1.64, 95% confidence interval [CI] = 0.91% to 2.37%) compared to those unexposed. Non-Hispanic other/multiracial children exposed to restaurant TSE had higher log-cotinine (ß = 1.13, 95% CI = 0.23% to 2.03%) compared to those unexposed. Among 12-17-year-olds, home SHS + THS exposure predicted higher log-cotinine among all racial and ethnic groups, except for non-Hispanic black adolescents. Car TSE predicted higher log-cotinine among all racial and ethnic groups. Non-Hispanic black adolescents with TSE in another indoor area had higher log-cotinine (ß = 2.84, 95% CI = 0.85% to 4.83%) compared to those unexposed. CONCLUSIONS: TSE location was uniquely associated with cotinine levels by race and ethnicity. Smoke-free home and car legislation are needed to reduce TSE among children and adolescents of all racial and ethnic backgrounds. IMPLICATIONS: Racial and ethnic disparities in TSE trends have remained stable among US children and adolescents over time. This study's results indicate that TSE locations differentially contribute to biochemically measured TSE within racial and ethnic groups. Home TSE significantly contributed to cotinine levels among school-aged children 6-11 years old, and car TSE significantly contributed to cotinine levels among adolescents 12-17 years old. Racial and ethnic differences in locations of TSE were observed among each age group. Study findings provide unique insight into TSE sources, and indicate that home and car smoke-free legislation have great potential to reduce TSE among youth of all racial and ethnic backgrounds.

Carcinogenic and tobacco smoke-derived particulate matter biomarker uptake and associated healthcare patterns among children.

BACKGROUND: The objective was to assess the associations of child tobacco smoke exposure (TSE) biomarkers (urinary cotinine, NNAL, and nicotelline N-oxides) and parent-reported smoking and child TSE patterns with total hospital visits, pediatric emergency department (PED) visits, urgent care (UC), revisits, and hospital admissions among 0-9-year-olds. METHODS: A convenience sample of PED/UC patients (N = 242) who presented to a large, US children's hospital who had baseline urine samples assayed for the TSE biomarkers of interest were included. Biomarker levels were log-transformed, and linear and Poisson regression models were built. RESULTS: The geometric means of child cotinine, creatinine-adjusted NNAL, and N-oxide levels were 11.2 ng/ml, 30.9 pg/mg creatinine, and 24.1 pg/ml, respectively. The mean (SD) number of daily cigarettes smoked by parents was 10.2 (6.1) cigarettes. Each one-unit increase in log-NNAL levels was associated with an increase in total UC visits (aRR = 1.68, 95% CI = 1.18-2.39) among 0-9-year-olds, while controlling for the covariates. Each one-unit increase in child log-NNAL/cotinine ratio (×103) values was associated with an increase in total hospital visits (aRR = 1.39, 95% CI = 1.10-1.75) and UC visits (aRR = 1.56, 95% CI = 1.14-2.13) over 6 months. CONCLUSION: Systematic screening for child TSE should be conducted during all hospital visits. The comprehensive assessment of TSE biomarkers should be considered to objectively measure young children's exposure. IMPACT: Higher levels of cotinine, a widely used tobacco smoke exposure biomarker, have been associated with higher healthcare utilization patterns among children. Less is known on the associations of carcinogenic and tobacco smoke-derived particulate matter biomarker uptake with child healthcare utilization patterns. This study assessed the associations of several biomarkers with healthcare utilization patterns among pediatric emergency department patients ages 0-9 years who lived with tobacco smokers. Higher urinary NNAL biomarker levels, in individual and ratio form with cotinine, increased children's risk for urgent care visits over 6 months. Higher parent-reported cumulative child tobacco smoke exposure increased children's risk for hospital admissions.

Improving trainee clinical documentation through a novel curriculum in internal medicine.

BACKGROUND: Clinical documentation is a key component of practice. Trainees rarely receive formal training in documentation or assessment of their documentation. Effective methods of improving documentation remain unknown. OBJECTIVE: The objective of this study was to determine if the implementation of a documentation curriculum led to improvement in admission note quality. DESIGNS: Admission notes written prior to implementation of the curriculum and after the curriculum intervention were assessed. Notes were assessed from two-time frames for both years to account for improvement with time not associated with the intervention. SETTINGS AND PARTICIPANTS: Admission notes written by University of Cincinnati interns were assessed. INTERVENTIONS: The documentation curriculum consisted of educational sessions and routine admission note assessments with feedback. MAIN OUTCOMES AND MEASURES: Admission notes were assessed via the 16 checklist items and two global assessment items of the Admission Note Assessment Tool (ANAT). RESULTS: Six ANAT items showed statistically significant differences. The review of systems item improved with the intervention only (odds ratio: 3.61, p < .001) while the assessment and plan item 1 and global assessment item 2 improved with time only (ß = .08, p = .03 and ß = .25, p = .02, respectively) in univariate models. In univariate models the physical exam item, diagnostic data item 2, and global assessment item 1 showed improvement with both intervention and time, respectively, with additive effects seen in models with both intervention and time. CONCLUSION: Several aspects of documentation can improve with a formal documentation curriculum which includes a routine assessment with feedback, and some aspects of documentation improve with time.

Tobacco smoke exposure and fractional exhaled nitric oxide levels among U.S. adolescents.

BACKGROUND: Fractional exhaled nitric oxide (FeNO) can objectively guide clinical practice in the assessment, diagnosis, and treatment of eosinophilic airway inflammation. FeNO values may be affected by current smoking, but the role of tobacco smoke exposure (TSE) is understudied. OBJECTIVE: This study investigated the associations between biochemically validated and self-reported TSE and FeNO levels among U.S. nonsmoking adolescents without asthma. METHODS: National Health and Nutrition Examination Survey 2007-2012 data were used. TSE was assessed via serum cotinine and self-reported measures. We assessed FeNO continuously and using cutpoints of >35 ppb and >50 ppb to indicate likely eosinophilic inflammation in children and adults, respectively. We conducted linear and logistic regression adjusting for potential covariates. RESULTS: Overall, 34.0% of adolescents had low cotinine (0.05-2.99 ng/ml), 6.2% had high cotinine (≥3.00 ng/ml), and 11.9% had home TSE. Compared to adolescents with no/minimal cotinine, adolescents with high cotinine were at reduced odds to have FeNO >35 ppb (adjusted odds ratio [aOR] = 0.54, 95%CI = 0.43,0.69). Adolescents with low cotinine had lower FeNO values (ß = -2.05, 95%CI = -3.61,-0.49), and were also at decreased odds to have FeNO >35 ppb (aOR = 0.74, 95%CI = 0.66,0.83) and FeNO >50 ppb (aOR = 0.62, 95%CI = 0.53,0.72). Adolescents with home TSE were at reduced odds to have FeNO >50 ppb (aOR = 0.72, 95%CI = 0.57,0.91) than adolescents without home TSE. Adolescents with a higher number of cigarettes/day smoked inside their home were at reduced odds to have FeNO >35 ppb (OR = 0.98, 95%CI = 0.97,0.99) and FeNO >50 ppb (OR = 0.98, 95%CI = 0.96,0.99). CONCLUSIONS: TSE was associated with decreased FeNO levels. The addition of TSE may be clinically important when interpreting thresholds for FeNO.

Differential associations of hand nicotine and urinary cotinine with children's exposure to tobacco smoke and clinical outcomes.

BACKGROUND: Children's overall tobacco smoke exposure (TSE) consists of both inhalation of secondhand smoke (SHS) and ingestion, dermal uptake, and inhalation of thirdhand smoke (THS) residue from dust and surfaces in their environments. OBJECTIVES: Our objective was to compare the different roles of urinary cotinine as a biomarker of recent overall TSE and hand nicotine as a marker of children's contact with nicotine pollution in their environments. We explored the differential associations of these markers with sociodemographics, parental smoking, child TSE, and clinical diagnoses. METHODS: Data were collected from 276 pediatric emergency department patients (Median age = 4.0 years) who lived with a cigarette smoker. Children's hand nicotine and urinary cotinine levels were determined using LC-MS/MS. Parents reported tobacco use and child TSE. Medical records were reviewed to assess discharge diagnoses. RESULTS: All children had detectable hand nicotine (GeoM = 89.7ng/wipe; 95 % CI = [78.9; 102.0]) and detectable urinary cotinine (GeoM = 10.4 ng/ml; 95%CI = [8.5; 12.6]). Although hand nicotine and urinary cotinine were highly correlated (r = 0.62, p < 0.001), urinary cotinine geometric means differed between racial groups and were higher for children with lower family income (p < 0.05), unlike hand nicotine. Independent of urinary cotinine, age, race, and ethnicity, children with higher hand nicotine levels were at increased risk to have discharge diagnoses of viral/other infectious illness (aOR = 7.49; 95%CI = [2.06; 27.24], p = 0.002), pulmonary illness (aOR = 6.56; 95%CI = [1.76; 24.43], p = 0.005), and bacterial infection (aOR = 5.45; 95%CI = [1.50; 19.85], p = 0.03). In contrast, urinary cotinine levels showed no associations with diagnosis independent of child hand nicotine levels and demographics. DISCUSSION: The distinct associations of hand nicotine and urinary cotinine suggest the two markers reflect different exposure profiles that contribute differentially to pediatric illness. Because THS in a child's environment directly contributes to hand nicotine, additional studies of children of smokers and nonsmokers are warranted to determine the role of hand nicotine as a marker of THS exposure and its potential role in the development of tobacco-related pediatric illnesses.

Evaluation of tobacco screening and counseling in a large, midwestern pediatric emergency department.

INTRODUCTION: The study objective was to assess tobacco screening and cessation counseling practices of pediatric emergency department (PED) and urgent care (UC) nurses and physicians, and factors associated with these practices. Secondarily, we assessed factors associated with performing tobacco smoke exposure reduction and tobacco cessation counseling. METHODS: We conducted a cross-sectional survey of 30 PED/UC nurses and physicians working at one large, urban, Midwestern children's hospital. Measures included current practices of performing the 5 As of tobacco counseling (Ask, Advise, Assess, Assist, Arrange), and attitude and practice factors that may influence practices. RESULTS: Overall, 90.0% of participants had not received recent tobacco counseling training, 73.3% were unaware of the 5 As, and 63.3% did not have a standardized, routine screening system to identify patients exposed to secondhand smoke. The majority of participants reported that they: asked about patients' secondhand smoke exposure status (70.0%) and parents' tobacco use status (53.3%), and advised parental smokers to not smoke around their child (70.0%) and to quit smoking (50%). One in five participants reported they assessed smokers' interest in quitting smoking, and 16.7% talked with smokers about cessation techniques and tactics; of these, 10% referred/enrolled smokers to the Tobacco Quitline or cessation program, and 6.7% made a quit plan or recommended nicotine replacement therapy medication. CONCLUSIONS: Key findings identified are the need for professional tobacco counseling training, standardizing efforts during visits, and emphasizing pediatric patients' potential health benefits. This information will be used for developing a PED/ UC-based parental tobacco cessation and child tobacco smoke exposure reduction intervention.

Combustible and electronic cigarette use and insufficient sleep among U.S. high school students.

The study aimed to investigate the relationships between current exclusive e-cigarette use, exclusive combustible cigarette smoking, and dual use of e-cigarettes and combustible cigarettes, and insufficient sleep among U.S. adolescents. We conducted a secondary data analysis of the 2017 Youth Risk Behavior Survey including 11,296 U.S. high school students. Current (past 30-day) tobacco use groups included exclusive e-cigarette users, exclusive combustible cigarette smokers, and dual-product users. We performed weighted unadjusted and adjusted logistic regression analyses. Insufficient sleep was defined as <8 h/night and < 7 h/night. Overall, 73.4% of adolescents reported insufficient sleep <8 h/night. Compared with non-tobacco users, exclusive e-cigarette users were more likely to report insufficient sleep <8 h/night (odds ratio [OR] = 1.55, 95%CI = 1.12-2.14; adjusted OR [aOR] = 1.57, 95%CI = 1.01-2.43) and < 7 h/night (OR = 1.55, 95%CI = 1.19-2.01; aOR = 1.61, 95%CI = 1.16-2.24). Dual-product users were at increased odds to report insufficient sleep <8 h/night (OR = 3.15, 95%CI = 1.87-5.32) and < 7 h/night (OR = 2.64, 95%CI = 1.87-3.72; aOR = 1.73, 95%CI = 1.14-2.62) than non-tobacco users. Exclusive combustible cigarette smokers were less likely to report insufficient sleep <8 h/night (aOR = 0.49, 95%CI = 0.29-0.84) than non-tobacco users, but no differences were found based on insufficient sleep <7 h/night. When comparing current use groups, exclusive e-cigarette users were at 3.20 increased odds (95%CI = 1.65-6.22) and dual-product users were at 3.26 increased odds (95%CI = 1.51-7.03) to report insufficient sleep <8 h/night when compared with exclusive combustible cigarette smokers after covariate adjustment. Dual-product users were 1.89 times more likely (95%CI = 1.01-3.51) to report insufficient sleep <7 h/night when compared with exclusive combustible cigarette smokers. School-based prevention efforts for tobacco use may promote sufficient sleep in youth.

Healthcare resources attributable to child tobacco smoke exposure.

BACKGROUND: Tobacco smoke exposure (TSE) places an economic toll on the U.S. healthcare system. There is a gap in the literature on pediatric emergency department (ED) and urgent care related healthcare costs and utilization specific to tobacco smoke-exposed patients. The objectives were to assess pediatric ED visits, urgent care visits and hospital admissions longitudinally, and baseline visit costs among tobacco smoke-exposed children (TSE group) relative to unexposed children (non-TSE group). METHODS AND FINDINGS: We conducted a retrospective study using electronic medical records of 380 children ages 0-17 years in the TSE group compared to 1,140 in the non-TSE group propensity score matched via nearest neighbor search by child age, sex, race, and ethnicity. Linear and Poisson regression models were used. Overall, children had a mean of 0.19 (SE = 0.01) repeat visits within 30-days, and 0.69 (SE = 0.04) pediatric ED visits and 0.87 (SE = 0.03) urgent care visits over 12-months following their baseline visit. The percent of children with ≥ 1 urgent care visit was higher among the TSE group (52.4%) than the non-TSE group (45.1%, p = 0.01). Children in the TSE group (M = $1,136.97, SE = 76.44) had higher baseline pediatric ED visit costs than the non-TSE group (M = $1,018.96, SE = 125.51, p = 0.01). Overall, children had 0.08 (SE = 0.01) hospital admissions over 12-months, and the TSE group (M = 0.12, SE = 0.02) had higher mean admissions than the non-TSE group (M = 0.06, SE = 0.01, p = 0.02). The child TSE group was at 1.85 times increased risk of having hospital admissions (95% CI = 1.23, 2.79, p = 0.003) than the non-TSE group. CONCLUSIONS: Tobacco smoke-exposed children had higher urgent care utilization and hospital admissions over 12-months, and higher pediatric ED costs at baseline. Pediatric ED visits, urgent care visits, and hospitalizations may be opportune times for initiating tobacco control interventions, which may result in reductions of preventable acute care visits.

High Cotinine and Healthcare Utilization Disparities Among Low-Income Children.

INTRODUCTION: This study assesses the associations of child salivary cotinine, parent-reported smoking, and child tobacco smoke exposure with the number of child healthcare visits and hospital admissions over a 6-month period. This study also assesses the relationships between participant characteristics and child cotinine. METHODS: Longitudinal data were evaluated from a sample of 313 clinically ill children aged 0-9 years who lived with a smoker and presented to a pediatric emergency department or urgent care in 2016-2018. In 2020, cotinine measurements were log transformed, and Poisson and linear regression were performed. RESULTS: The majority of the children came from low-income homes (66.1%) and had public insurance/self-pay (95.5%). Child cotinine concentrations ranged from 0.1 to 332.0 ng/mL (geometric mean=4.8 ng/mL, 95% CI=4.1, 5.5). Poisson regression results indicated that each 1-unit increase of log-cotinine concentration was associated with an increase in pediatric emergency department visits over a 6-month period after the baseline visit, with an adjusted RR of 1.16 (95% CI=1.01, 1.34). Each 1-unit increase of log-cotinine concentration was associated with an increase in the frequency of hospital admissions over the 6-month period, with an adjusted RR of 1.50 (95% CI=1.08, 2.09). No differences were found between parent-reported smoking or child tobacco smoke exposure and healthcare utilization. Linear regression results indicated that children who were younger (ß= -0.227, p=0.049), were White (geometric mean=5.5 ng/mL), had a medical history of prematurity (geometric mean=8.1 ng/mL), and had a winter baseline visit (geometric mean=6.5 ng/mL) had higher cotinine concentrations. Children living in apartments (geometric mean=5.5 ng/mL) and multiunit homes (geometric mean=5.5 ng/mL) had higher cotinine concentrations than those in single-family homes (geometric mean=3.6 ng/mL). CONCLUSIONS: Routine biochemical screening could identify children who are in need of intensive tobacco smoke exposure reduction interventions.

Blunt cerebrovascular injury in the geriatric population.

OBJECTIVE: Blunt cerebrovascular injury (BCVI) is associated with high rates of neurological morbidity and mortality. The detection and management of BCVI has improved with advances in imaging and sensitive screening protocols. Few studies have explored how these injuries specifically affect the geriatric population. The purpose of this retrospective analysis was to investigate the presentation and prognosis of BCVI in the elderly population and to assess its clinical implications in the management of these patients. METHODS: All patients presenting to the University of Cincinnati (UC) level I trauma center between February 2017 and December 2019 were screened for BCVI and entered into the prospectively maintained UC Neurotrauma Registry. Patients with BCVI confirmed by CT angiography underwent retrospective chart reviews to collect information regarding demographics, positive screening criteria, cause of injury, antithrombotic agent, injury location, Denver Grading Scale, hospital and ICU length of stay, and discharge disposition. Patients were divided into geriatric (age ≥ 65 years) and adult (age < 65 years) subgroups. Continuous variables were analyzed using the Student t-test and categorical variables with the Pearson chi-square test. RESULTS: Of 124 patients with BCVI, stratification by age yielded 23 geriatric and 101 adult patients. Injury in the geriatric group was associated with significantly higher mortality (p = 0.0194). The most common cause of injury in the elderly was falls (74%, 17/23; p < 0.0001), whereas motor vehicle accidents were most common in the adult group (38%, 38/100; p = 0.0642). With respect to the location of injury, carotid (p = 0.1171) and vertebral artery (p = 0.6981) injuries did not differ significantly for the geriatric group. The adult population presented more often with Denver grade I injuries (p < 0.0001), whereas the geriatric population presented with grade IV injuries (p = 0.0247). Elderly patients were more likely to be discharged to skilled nursing facilities (p = 0.0403) and adults to home or self-care (p = 0.0148). CONCLUSIONS: This study is the first to characterize BCVI to all cervical and intracranial vessels in the geriatric population. Older age at presentation is significantly associated with greater severity, morbidity, and mortality from injury, with no preference for the particular artery injured. These findings carry important clinical implications for adapting practice in an aging population.

Resting Borg score as a predictor of safe discharge of chronic obstructive pulmonary disease from the emergency department observation unit.

BACKGROUND: Chronic obstructive pulmonary disease exacerbations (eCOPD) can be life-threatening and costly. Emergency department (ED) observation units (ED-Obs) offer short-term care to safely reduce preventable hospitalizations. Accurately identifying eCOPD patients who can be discharged safely will improve outcomes. OBJECTIVES: The objective were to: I) evaluate utility of conventional clinical variables as predictors of safe discharge and II) assess utility of serial resting Borg score and novel Dyspnea Assessment Score (DAS) for identifying eCOPD patients who can be safely discharged from ED-Obs. METHODS: This study was carried out in a 680-bed tertiary, academic hospital with >700 annual eCOPD ED encounters and a 16-bed ED-Obs. A two-phase study of eCOPD patients admitted to ED-Obs was performed. Objective I was a retrospective study including all eCOPD admits from April 2016 to May 2017. Predictor variables (demographics, COPD severity, comorbid conditions, exacerbation severity, clinical care in ED) and outcome variables (ED-Obs disposition, ED revisits) were obtained through electronic medical records. Safe discharge was defined as home disposition from ED-Obs without 7-day revisit. A stepwise regression was performed for predictors of safe discharge. Objective II was a prospective observation study for change in every 4-hour serial resting Borg score and DAS as identifiers of safe discharge. Comparative and receiver operating characteristic (ROC) analyses were performed. A p-value of <0.05 was considered significant. RESULTS: In Objective I, 171 patients with age, FEV1 %, and body mass index of 59.8 (±9.5) years, 35 (±24)%, and 28.8 (±8) m2 /kg were included. After ED-Obs treatment 78 (45.6%) were hospitalized and 93 (54.4%) were discharged home, of whom 11 (6.4%) had 7-day ED revisit. Safe discharge occurred in 82 (48%). None of the predictor variables correlated with safe discharge. In Objective II, of 38 patients included, 20 (52.6%) had safe discharge. Among others, 16 (42%) were hospitalized and two (5.2%) had 7-day ED revisit. The admission Borg scores and DASs were similar in both groups. The predisposition Borg score was significantly lower in patients with safe discharge (2.75 vs. 5.28, p < 0.001) and had the highest area under curve on ROC (0.77) for safe discharge. DAS was not significantly different between groups. CONCLUSIONS: Routine clinical variables do not identify eCOPD patients who can be safely discharged from ED-Obs. Change in resting Borg score during the course of ED-Obs treatment safely identifies patients for discharge. Prospective, external validation is needed to incorporate serial Borg scores in ED-Obs disposition decision for improved safety.

Child tobacco smoke exposure and healthcare resource utilization patterns.

BACKGROUND: The objective was to examine the relationship between healthcare resource utilization patterns in tobacco smoke-exposed children (TSE group) compared with unexposed children (non-TSE group). METHODS: We matched 380 children in the TSE group with 1140 children in the non-TSE group based on child age, sex, race, and ethnicity using propensity scores. Healthcare resource utilization variables included respiratory-related procedures, diagnostic testing, disposition, and medications. Logistic and linear regression models were built. RESULTS: Child mean age was 4.9 (SD = 0.1) years, 50.5% were female, 55.5% black, and 73.2% had public insurance/self-pay. Compared to the non-TSE group, the TSE group was at increased odds to have the following performed/obtained: nasal bulb suctioning, infectious diagnostic tests, laboratory tests, and radiologic tests. The TSE group was more likely to be admitted to the hospital, and more likely to receive steroids and intravenous fluids during their visit. Among asthmatics, the TSE group was more likely to receive steroids, albuterol, or ipratropium alone, or a combination of all three medications during their visit, and be prescribed albuterol alone or steroids and albuterol. CONCLUSION: Tobacco smoke-exposed children are more likely to have higher resource utilization patterns, highlighting the importance of screening and providing TSE prevention and remediation interventions. IMPACT: Tobacco smoke exposure may affect the healthcare resource utilization patterns of children. Evidence is lacking concerning these associations among the highly vulnerable pediatric emergency department patient population. This study examined the association between tobacco smoke exposure and healthcare resource utilization patterns among pediatric emergency department patients. Tobacco smoke exposure increased the risk of pediatric patients having respiratory-related procedures, respiratory-related and non-respiratory-related testing, medications administered during the pediatric emergency department visit, and medications prescribed for home administration. Tobacco smoke-exposed patients were more likely to be admitted to the hospital compared to unexposed patients.

Tobacco Smoke Exposure, Respiratory Health, and Health-care Utilization Among US Adolescents.

BACKGROUND: Tobacco smoke exposure adversely affects respiratory health. However, the effects of exposure on adolescents without asthma are not well known. RESEARCH QUESTION: To what degree are biochemically measured and self-reported tobacco smoke exposure associated with pulmonary function and health-care utilization among US nonsmoking adolescents? STUDY DESIGN AND METHODS: We analyzed 2007-2012 National Health and Nutrition Examination Survey data (N = 2,482). Tobacco smoke exposure was assessed with serum cotinine and self-reported home exposure. We built multiple regression, logistic regression, and Poisson regression models, depending on the outcome. RESULTS: Approximately 3% of adolescents had high cotinine (3.00-15.00 ng/mL), 35.7% had low cotinine (0.05-2.99 ng/mL), and 10.9% had home exposure. Adolescents with high cotinine had significantly lower FEV1% (mean, 97.4; SE, 2.09; ß, -8.99; 95% CI, -15.64 to -2.33) and FVC% (mean, 97.4; SE, 2.06; ß, -8.42; 95% CI, -14.74 to -2.11) than adolescents with no/minimal cotinine (< 0.05 ng/mL; mean, 101.0; SE, 0.45; mean, 99.9; SE, 0.46, respectively). Adolescents with high cotinine were less likely to have a past year health-care visit (adjusted OR [aOR], 0.57; 95% CI, 0.38 to 0.88), but more likely to have an overnight hospital stay (aOR, 4.82; 95% CI, 2.58 to 9.00), and at increased risk of having a higher number of overnight hospital stays (adjusted relative risk [aRR], 4.04; 95% CI, 2.27 to 7.21). Adolescents with low cotinine were less likely to have a health-care visit (aOR, 0.84; 95% CI, 0.71 to 0.99), but more likely to have an overnight hospital stay (aOR, 4.82; 95%CI, 2.58 to 9.00) than adolescents with no/minimal cotinine. Adolescents with low cotinine were at increased risk of having a higher number of health-care visits (aRR, 1.06; 95% CI, 1.02 to 1.11) and overnight hospital stays (aRR, 2.02; 95% CI, 1.46 to 2.81). Adolescents with home exposure had lower FEV1% (mean, 99.9; SE, 1.17; ß, -5.11; 95% CI, -9.26 to -0.96) and FVC% (mean, 100.0; SE, 1.16; ß, -5.36; 95% CI, -9.30 to -1.42) than adolescents with no home exposure (mean, 101.0; SE, 0.38; mean, 100.2; SE, 0.39, respectively). Adolescents with home exposure were more likely to have an overnight hospital stay (aOR, 5.65; 95% CI, 3.66 to 8.73) and at increased risk of having a higher number of overnight hospital stays (aRR, 4.08; 95% CI, 2.76 to 6.03). INTERPRETATION: Detectable serum cotinine levels and self-reported home exposure were distinctively associated with decreased pulmonary function and increased health-care utilization.

Development and Establishment of Initial Validity Evidence for a Novel Tool for Assessing Trainee Admission Notes.

BACKGROUND: Documentation is a key component of practice, yet few curricula have been published to teach trainees proper note construction. Additionally, a gold standard for assessing note quality does not exist, and no documentation assessment tools integrate with established competency-based frameworks. OBJECTIVE: To develop and establish initial validity evidence for a novel tool that assesses key components of trainee admission notes and maps to the Accreditation Council for Graduate Medical Education (ACGME) milestone framework. DESIGN: Using an iterative, consensus building process we developed the Admission Note Assessment Tool (ANAT). Pilot testing was performed with both the supervising attending and study team raters not involved in care of the patients. The finalized tool was piloted with attendings from other institutions. PARTICIPANTS: Local experts participated in tool development and pilot testing. Additional attending physicians participated in pilot testing. MAIN MEASURES: Content, response process, and internal structure validity evidence was gathered using Messick's framework. Inter-rater reliability was assessed using percent agreement. KEY RESULTS: The final tool consists of 16 checklist items and two global assessment items. Pilot testing demonstrated rater agreement of 72% to 100% for checklist items and 63% to 70% for global assessment items. Note assessment required an average of 12.3 min (SD 3.7). The study generated validity evidence in the domains of content, response process, and internal structure for use of the tool in rating admission notes. CONCLUSIONS: The ANAT assesses individual components of a note, incorporates billing criteria, targets note "bloat," allows for narrative feedback, and provides global assessments mapped to the ACGME milestone framework. The ANAT can be used to assess admission notes by any attending and at any time after note completion with minimal rater training. The ANAT allows programs to implement routine note assessment for multiple functions with the use of a single tool.

Characteristics of Daily E-Cigarette Use and Acquisition Means Among a National Sample of Adolescents.

PURPOSE: To examine the relationship between several e-cigarette-related characteristics and daily e-cigarette use among adolescent current users. DESIGN: Secondary analysis of 2016 National Youth Tobacco Survey data. SETTING: United States middle schools and high schools. SAMPLE: One thousand five hundred seventy-nine current e-cigarette users. MEASURES: Daily e-cigarette use and e-cigarette flavors, brands, device type, and acquisition were measured. ANALYSIS: Logistic regression and Poisson regression models were built. RESULTS: A total of 13.6% of current users reported daily use. Results indicated that daily users were at increased odds of using all flavor types (all P < .001), with the exception of menthol/mint, and using a higher number of flavors than nondaily users (P < .001). Daily users were more likely to use Blu, eGo, Logic, Halo, NJOY, and another unlisted brand but less likely to report they did not know the brand used (all P ≤ .01). Daily users also reported using a higher number of brands than nondaily users (P < .001). Daily users were at increased odds of using marijuana/tetrahydrocannabinol (THC) oil wax as device ingredients (P < .001) and less likely to use only nicotine (P < .001) or unknown ingredients (P = .004). Daily users were more likely to acquire e-cigarettes from a vape shop, gas station/convenience store, Internet, mall/shopping center kiosk, drug store, grocery store, or other place (all P ≤ .01). CONCLUSION: Comprehensive efforts are needed to reduce e-cigarette use and nicotine addiction among adolescents.