The LACE index and risk factors of 14-day versus 30-day readmissions in children.

Risk factors for readmissions in children differ from those in adults, yet little is known about whether the LACE index (Length of stay, Acute admission, Charlson comorbidity index, Emergency department visits in the previous 6 months) developed for adults retains its validity when applied to the prediction of readmissions in children or within shorter intervals of time after discharge. In this retrospective cohort analysis of 4256 patients aged ≤18 years hospitalized at one academic medical center in Taiwan in 2019, we first evaluated the performance of a LACE index model and the three other multivariate logistic regression models in their predictions of hospital readmissions in children using the same time interval of 30 days. We then used multinomial logistic regression to analyze the characteristics and risk factors for readmissions that occur in the first 14 days with those that occur between 15 and 30 days after discharge. The optimal cut-off of the LACE index score for children in the current study was 7, which is less than the optimal score of 10 in the original derivation for adults. The predictive model with the least discriminatory power was based on the LACE score alone, whereas our model that included only two variables (length of stay and the number of admissions in the past 1 year) was found to outperform the LACE index. Multinomial logistic regression results revealed that children who had supplemental private health insurance had lower readmission rates than those insured by the National Health Insurance program only, suggesting a disparity by insurance status. Some risk factors of readmission within 14 days such as acute admissions and supplemental private health insurance were not found to be relevant for longer-term predictions, while age, which was a valid predictor of readmission within 15-30 days, did not affect the prediction of shorter-term readmissions. Prior health care utilization and a higher illness burden were found to be greater contributors to readmissions beyond 14 days. Our simpler model outperformed the more complex LACE tool in identifying children at risk of readmission. Shorter-term readmissions can be attributed to different causes than 30-day readmissions, suggesting a need for different screening tools, interventions, and care support. There remains some socioeconomic disparity associated with readmission rates in the current health care system.

Early prediction of 30- and 14-day all-cause unplanned readmissions.

BACKGROUND: An unplanned readmission is a dual metric for both the cost and quality of medical care. METHODS: We employed the random forest (RF) method to build a prediction model using a large dataset from patients' electronic health records (EHRs) from a medical center in Taiwan. The discrimination abilities between the RF and regression-based models were compared using the areas under the ROC curves (AUROC). RESULTS: When compared with standardized risk prediction tools, the RF constructed using data readily available at admission had a marginally yet significantly better ability to identify high-risk readmissions within 30 and 14 days without compromising sensitivity and specificity. The most important predictor for 30-day readmissions was directly related to the representing factors of index hospitalization, whereas for 14-day readmissions the most important predictor was associated with a higher chronic illness burden. CONCLUSIONS: Identifying dominant risk factors based on index admission and different readmission time intervals is crucial for healthcare planning.

Influencing factors in the simulation of airflow and particle transportation in aircraft cabins by CFD.

To control the transport of particles such as the SARS-CoV-2 virus in airliner cabins, which is a significant concern for the flying public, effective ventilation systems are essential. Validated computational fluid dynamics (CFD) models are frequently and effectively used to investigate air distribution and contaminant transportation. The complex geometry and airflow characteristics in airliner cabins pose a challenge to numerical CFD validation. The objective of this investigation was to identify accurate and affordable validation processes for studying the airflow field and particulate contaminant distribution in airliner cabins during the design process for different ventilation systems. This study quantitatively evaluated the effects of ventilation system, turbulence model, particle simulation method, geometry simplification, and boundary condition assignment on airflow and particulate distributions in airliner cabins with either a mixing ventilation (MV) system or a displacement ventilation (DV) system calculated by CFD. The results showed that among four turbulence models, the standard k-ε, RNG k-ε, realizable k-ε and SST k-ω models, the prediction by the realizable k-ε model agreed most closely with the experimental data. Meanwhile, the steady Eulerian method provided a reasonable prediction of the particle concentration field with low computing cost. The computational domain should be simplified differently for the DV system and the MV system with consideration of the simulation accuracy and computing cost. For more accurate modeling results, the boundary conditions should be assigned in greater detail, taking into account the uniformity on the boundary.

Corrigendum to "Evaluation of different air distribution systems in a commercial airliner cabin in terms of comfort and COVID-19 infection risk" Build. Environ., Volume 208, January 2022, 108590.

[This corrects the article DOI: 10.1016/j.buildenv.2021.108590.].

Identification of key volatile organic compounds in aircraft cabins and associated inhalation health risks.

The identification of key VOCs during flights is important in creating a satisfactory aircraft cabin environment. Two VOC databases for the building indoor environment (from 251 occupied residences) and the aircraft cabin environment (from 56 commercial flights) were compared, to determine the common compounds (detection rate (DR) > 70%) in the two environments and the characteristic VOCs (only those with high DR during flights) in aircraft cabins. Possible VOC emission sources in flights were also discussed. As TVOC is usually viewed as a general indicator of air quality, the prediction of TVOC concentration was carried out using BP neural network algorithm, and the average error between the predicted and measured values was 55.35 µg/m3 (R2 = 0.80). Meanwhile, the VOCs' inhalation cancer/non-cancer risks to crew members and passengers were calculated on the basis of detection rates, exposure concentrations, and health risk assessments. Six compounds (i.e., formaldehyde, benzene, tetrachloroethylene, trichloromethane, 1,2-dichloroethane, and naphthalene) were proposed as the key VOCs in the existing aircraft cabin environment, presenting a risk to crew members that is higher than the US EPA proposed acceptable level (evaluated mean value > 1E-06). The estimated lifetime excess cancer/non-cancer risks for passengers were all below the assessment criteria. Based on a summary of various VOC limits in five built environments, hierarchical design of VOC concentration limits is recommended for the aircraft environment.

Evaluation of different air distribution systems in a commercial airliner cabin in terms of comfort and COVID-19 infection risk.

The air distribution system in an airliner plays a key role in maintaining a comfortable and healthy environment in the aircraft cabin. To evaluate the performance of a novel displacement ventilation (DV) system and a traditional mixing ventilation (MV) system in an airliner cabin, this study conducted experiments and simulations in a seven-row cabin mockup. This investigation used ultrasonic anemometers and T-thermocouples to measure the air velocity, temperature and distribution of 1 µm and 5 µm particles. Simulation verifications were performed for these operating conditions, and additional scenarios with different occurrence source locations were also simulated. This study combined the Wells-Riley equation with a real case based on a COVID-19 outbreak among passengers on a long-distance bus to obtain the COVID-19 quanta value. Through an evaluation of the airflow organization, thermal comfort, and risk of COVID-19 infection, the two ventilation systems were compared. This investigation found that polydisperse particles should be used to calculate the risk of infection in airliner cabins. In addition, at the beginning of the pandemic, the infection risk with DV was lower than that with MV. In the middle and late stages of the epidemic, the infection risk with MV can be reduced when passengers wear masks, leading to an infection risk approximately equal to that of DV.

Comparison of Back-Propagation Neural Network, LACE Index and HOSPITAL Score in Predicting All-Cause Risk of 30-Day Readmission.

BACKGROUND: The main purpose of this study is to predict the all-cause risk of 30-day readmission by employing the back-propagation neural network (BPNN) in comparison with traditional risk assessment tools of LACE index and HOSPITAL scores. METHODS: This was a retrospective cohort study from January 1st, 2018 to December 31st, 2019. A total of 55,688 hospitalizations from a medical center in Taiwan were examined. The LACE index (length of stay, acute admission, Charlson comorbidity index score, emergency department visits in previous 6 months) and HOSPITAL score (hemoglobin level at discharge, discharge from an Oncology service, sodium level at discharge, procedure during hospital stay, Index admission type, number of hospital admissions during the previous year, length of stay) are calculated. We employed variables from LACE index and HOSPITAL score as the input vector of BPNN for comparison purposes. RESULTS: The BPNN constructed in the current study has a considerably better ability with a C statistics achieved 0.74 (95% CI 0.73 to 0.75), which is statistically significant larger than that of the other two models using DeLong's test. Also, it was possible to achieve higher sensitivity (70.32%) without penalizing the specificity (71.76%) and accuracy (71.68%) at its optimal threshold, which is at the 20% of patients with the highest predicted risk. Moreover, it is much more informative than the other two methods because of a considerably higher LR+ and a lower LR-. CONCLUSION: Our findings suggest that more attention should be paid to methods based on non-linear classification systems, as they lead to substantial differences in risk-scores.

Influencing factors of carbonyl compounds and other VOCs in commercial airliner cabins: On-board investigation of 56 flights.

Volatile organic compounds (VOCs) as a non-negligible aircraft cabin air quality (CAQ) factor influence the health and comfort of passengers and crew members. On-board measurements of carbonyls (short-chain (C1 -C6 )) and other volatile organic compounds (VOCs, long-chain (C6 -C16 )) with a total of 350 samples were conducted in 56 commercial airliner cabins covering 8 aircraft models in this study. The mean concentration for each individual carbonyl compound was between 0.3 and 8.3 µg/m3 (except for acrolein & acetone, average = 20.7 µg/m3 ) similar to the mean concentrations of other highly detected VOCs (long-chain (C6 -C16 ), 97% of which ranged in 0-10 µg/m3 ) in aircraft cabins. Formaldehyde concentrations in flights were significantly lower than in residential buildings, where construction materials are known formaldehyde sources. Acetone is a VOC emitted by humans, and its concentration in flights was similar to that in other high-occupant density transportation vehicles. The variation of VOC concentrations in different flight phases of long-haul flights was the same as that of CO2 concentration except for the meal phase, which indicates the importance of cabin ventilation in diluting the gaseous contaminants, while the sustained and slow growth of the VOC concentrations during the cruising phase in short-haul flights indicated that the ventilation could not adequately dilute the emission of VOCs. For the different categories of VOCs, the mean concentration during the cruising phase of benzene series, aldehydes, alkanes, other VOCs (detection rate > 50%), and carbonyls in long-haul flights was 44.2 µg/m3 , 17.9 µg/m3 , 18.6 µg/m3 , 31.5 µg/m3 , and 20.4 µg/m3  lower than those in short-haul flights, respectively. Carbonyls and d-limonene showed a significant correlation with meal service (p < 0.05). Unlike the newly decorated rooms or new vehicles, the inner materials were not the major emission sources in aircraft cabins. Practical Implications. The on-board measurements of 56 flights enrich the VOC database of cabin environment, especially for carbonyls. The literature review of carbonyls in the past 20 years contributes to the understanding the current status of cabin air quality (CAQ). The analysis of VOC concentration variation for different flight phases, flight duration, and aircraft age lays a foundation for exploring effective control methods, including ventilation and purification for cabin VOC pollution. The enriched VOC data is helpful to explore the key VOCs of aircraft cabin environment and to evaluate the acute/chronic health exposure risk of pollutants for passengers and crew members.

Experimental evaluation of particle exposure at different seats in a single-aisle aircraft cabin.

During the COVID-19 pandemic, exposure to particles exhaled by infected passengers in commercial aircraft cabins has been a great concern. Currently, aircraft cabins adopt mixing ventilation. However, complete mixing may not be achieved, and thus the particle concentration in the respiratory zone may vary from seat to seat in a cabin. To evaluate the particle exposure in a typical single-aisle aircraft cabin, this investigation constructed an aircraft cabin mockup for experimental tests. Particles were released from a single source or dual sources at different seats to represent particles exhaled by infected passengers. The particle concentrations in the respiratory zones at various seats were measured and compared. The particle exposure was evaluated in both a cross section and a longitudinal section. Leaving the middle seat vacant to reduce particle exposure was also addressed. In addition, the velocity fields and air temperatures were measured to provide a better understanding of particle transport. It was found that the particle exposure at the window seat is always the lowest, regardless of the particle release locations. If the passenger seated in the middle does not release particles, his/her presence enhances the particle dispersion and thereby reduces the particle exposure for adjacent passengers. In the cabin mockup, the released particles can be transported across at least four rows of seats in the longitudinal direction.

Evaluating the commercial airliner cabin environment with different air distribution systems.

Ventilation systems for commercial airliner cabins are important in reducing contaminant transport and maintaining thermal comfort. To evaluate the performance of a personalized displacement ventilation system, a conventional displacement ventilation system, and a mixing ventilation system, this study first used the Wells-Riley equation integrated with CFD to obtain the SARS quanta value based on a specific SARS outbreak on a flight. This investigation then compared the three ventilation systems in a seven-row section of a fully occupied, economy-class cabin in Boeing 737 and Boeing 767 airplanes. The SARS quanta generation rate obtained for the index patient could be used in future studies. For all the assumed source locations, the passengers' infection risk by air in the two planes was the highest with the mixing ventilation system, while the conventional displacement ventilation system produced the lowest risk. The personalized ventilation system performed the best in maintaining cabin thermal comfort and can also reduce the infection risk. This system is recommended for airplane cabins.

Prediction of particle deposition around the cabin air supply nozzles of commercial airplanes using measured in-cabin particle emission rates.

Enhanced soiling on the surfaces around air supply nozzles due to particle deposition is frequently observed in commercial airliners. The problem is worsened by severe outdoor air pollution and flight delays in China. The particles in an aircraft cabin originate from both outdoor and in-cabin sources. This study conducted measurements on multiple commercial flights to obtain particle emission rates from in-cabin sources. Additional experiments on a retired MD-82 airplane provided justification of the in-flight measurements. The in-cabin sources emitted more particles during boarding/deplaning than during meal servicing and sitting. The average PM2.5 emission rates were 7.2, 2.6, 1.9, and 1.8 (µg/min per person), respectively, during the boarding/deplaning, sitting on the ground, sitting in the air, and meal servicing. The corresponding PM10 emission rates were 15.4, 6.1, 5.3, and 5.4 (µg/min per person), respectively, for these four periods. The average particle emission rate from in-cabin sources varied seasonally and was the highest in winter. With the measured data, this investigation used a CFD model to predict the accumulation of particles deposited around the nozzles of an airplane, taking into account the flight routes and the outdoor particle concentrations at the airports where the airplanes were parked. For the most polluted airplane in China, the dirty spots/areas around the nozzles inside the airplane became visible after 6 months. The method proposed in this study can be used for any commercial airplane to predict the accumulation of particles deposited around the air supply nozzles.

An innovative personalized displacement ventilation system for airliner cabins.

In airliner cabins, mixing ventilation systems with gaspers are not efficient in controlling contaminant transport. To improve the cabin environment, this investigation proposed an innovative ventilation system that would reduce contaminant transport and maintain thermal comfort. We manufactured and installed the proposed ventilation system in an occupied seven-row, single-aisle aircraft cabin mockup. Air velocity, air temperature, and contaminant distribution in the cabin mockup were obtained by experimental measurements. The investigation used the experimental data to validate the results of CFD simulation. The validated CFD program was then used to study the impact of the locations and number of exhausts on contaminant removal and thermal comfort in a one-row section of a fully occupied Boeing-737 cabin. Although the diffusers in the proposed system were close to the passengers' legs, the air velocity magnitude was acceptable in the lower part of the cabin and the leg area. The proposed system provided an acceptable thermal environment in the cabin, although passengers could feel cold when placing their legs directly in front of the diffusers. The four-exhaust configuration of the new ventilation system was the best, and it decreased the average exposure in the cabin by 57% and 53%, respectively, when compared with the mixing and displacement ventilation systems.

Logistic growth of a surface contamination network and its role in disease spread.

Surfaces and objects surround us, and touching them is integral to everyday life. Pathogen contaminated surfaces (fomites) are known to transmit diseases. However, little is known about the ways and speed at which surfaces become contaminated. We found that under certain conditions, the number of contaminated surfaces grows logistically, corresponding to possible rapid transmission of infection. In such a surface network, pathogen can be transmitted great distances quickly-as far as people move. We found that the surface contamination network in aircraft cabins exhibits a community structure, with small communities connected by the aisle seatback surfaces and toilets, which are high-touch surfaces. In less than two to three hours, most high-touch surfaces in the cabin are contaminated, and within five to six hours nearly all touchable surfaces are contaminated. During short haul flight, aisle passengers have higher fomite exposure. This closely matches the spatial infection pattern of one reported inflight norovirus outbreaks. Our model is generally applicable to other crowded settings. The commonly repeated advice to "wash hands frequently" may be replaced in future by more strategic advice such as "clean surfaces right now", or advice based on who should wash their hands, and when.

Design and characterization of a cough simulator.

Expiratory droplets from human coughing have always been considered as potential carriers of pathogens, responsible for respiratory infectious disease transmission. To study the transmission of disease by human coughing, a transient repeatable cough simulator has been designed and built. Cough droplets are generated by different mechanisms, such as the breaking of mucus, condensation and high-speed atomization from different depths of the respiratory tract. These mechanisms in coughing produce droplets of different sizes, represented by a bimodal distribution of 'fine' and 'coarse' droplets. A cough simulator is hence designed to generate transient sprays with such bimodal characteristics. It consists of a pressurized gas tank, a nebulizer and an ejector, connected in series, which are controlled by computerized solenoid valves. The bimodal droplet size distribution is characterized for the coarse droplets and fine droplets, by fibrous collection and laser diffraction, respectively. The measured size distributions of coarse and fine droplets are reasonably represented by the Rosin-Rammler and log-normal distributions in probability density function, which leads to a bimodal distribution. To assess the hydrodynamic consequences of coughing including droplet vaporization and polydispersion, a Lagrangian model of droplet trajectories is established, with its ambient flow field predetermined from a computational fluid dynamics simulation.

Investigating the impact of gaspers on cabin air quality in commercial airliners with a hybrid turbulence model.

It is not clear whether turning on the gaspers in the cabins of commercial airliners actually improves the air quality. To answer this question, this study first developed a hybrid turbulence model which was suitable for predicting the air distribution in an aircraft cabin with gaspers turned on. Next, the investigation validated the model using two sets of experimental data from a cabin mockup and an actual airplane. This study then used the validated model to systematically investigate the impact of gaspers on cabin air quality in a seven-row section of the fully-occupied, economy-class cabin of Boeing 767 and 737 airplanes. The CFD calculations formed a database consisting of 9660 data points that provide information about SARS infection risk. It was found that the distribution of opened gaspers can influence the infection risk for passengers. Even though the gasper supplies clean air, it is possible for it to have a negative impact on the passengers' health. Statistically speaking, the overall effect of turning on the gaspers on the mean infection risk for the general population was neutral.

A Markov chain model for predicting transient particle transport in enclosed environments.

Obtaining information about particle dispersion in a room is crucial in reducing the risk of infectious disease transmission among occupants. This study developed a Markov chain model for quickly obtaining the information on the basis of a steady-state flow field calculated by computational fluid dynamics. When solving the particle transport equations, the Markov chain model does not require iterations in each time step, and thus it can significantly reduce the computing cost. This study used two sets of experimental data for transient particle transport to validate the model. In general, the trends in the particle concentration distributions predicted by the Markov chain model agreed reasonably well with the experimental data. This investigation also applied the model to the calculation of person-to-person particle transport in a ventilated room. The Markov chain model produced similar results to those of the Lagrangian and Eulerian models, while the speed of calculation increased by 8.0 and 6.3 times, respectively, in comparison to the latter two models.

Constructing "behavioral" comparison groups: A difference-in-difference analysis of the effect of copayment based on the patient's price elasticity.

It is well known that the differences-in-differences (DD) estimator is based on the assumption that in the absence of treatment, the average outcomes for the treated group and the control group will follow a common trend over time. That can be problematic, especially when the selection for the treatment is influenced by the individual's unobserved behavior correlating with the medical utilization. The aim of this study was to develop an index for controlling a patient's unobserved heterogeneous response to reform, in order to improve the comparability of treatment assignment. This study showed that a DD estimator of the reform effects can be decomposed into effects induced by moral hazard and by changes in health risk within the same treated/untreated group. This article also presented evidence that the constructed index of the price elasticity of the adjusted clinical group has good statistical properties for identifying the impact of reform.

Experimental study of gaseous and particulate contaminants distribution in an aircraft cabin.

The environment of the aircraft cabin greatly influences the comfort and health of passengers and crew members. Contaminant transport has a strong effect on disease spreading in the cabin environment. To obtain the complex cabin contaminant distribution fields accurately and completely, which is also essential to provide solid and precise data for computational fluid dynamics (CFD) model validation, this paper aimed to investigate and improve the method for simultaneous particle and gaseous contaminant fields measurement. The experiment was conducted in a functional MD-82 aircraft. Sulfur hexafluoride (SF6) was used as tracer gas, and Di-Ethyl-Hexyl-Sebacat (DEHS) was used as particulate contaminant. The whole measurement was completed in a part of the economy-class cabin without heating manikins or occupied with heating manikins. The experimental method, in terms of pollutant source setting, sampling points and schedule, was investigated. Statistical analysis showed that appropriately modified sampling grid was able to provide reasonable data. A small difference in the source locations can lead to a significant difference in cabin contaminant fields. And the relationship between gaseous and particulate pollutant transport was also discussed through tracking behavior analysis.