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1.  Incidence of Adult-onset Asthma After Hypothetical Interventions on Body Mass Index and Physical Activity: An Application of the Parametric G-Formula 
American Journal of Epidemiology  2013;179(1):20-26.
High body mass index (BMI) (calculated as weight (kg)/height (m)2) is associated with increased asthma risk, but uncertainty persists about the role of physical activity. We estimated the independent and joint associations of hypothetical interventions on BMI and physical activity with the risk of adult-onset asthma in 76,470 asthma-free women from the Nurses’ Health Study who were followed between 1988 and 1998. Information about asthma, BMI, physical activity, and other factors was updated every 2 years. We used the parametric g-formula to estimate the 10-year asthma risk in the following 4 scenarios: no intervention, 5% BMI reduction in a 2-year period for those who were overweight or obese, at least 2.5 hours/week of moderate-to-vigorous physical activity, and both of the previous 2 interventions. At baseline, women had a mean age of 55 (standard deviation, 7) years and a mean BMI of 25.4 (standard deviation, 4.8). Median time spent in physical activity was 0.7 hours/week. During follow-up, 1,146 women developed asthma. The 10-year asthma risk under no intervention was 1.5%. Compared with no intervention, the population risk ratios were 0.96 (95% confidence interval (CI): 0.93, 0.99) under the BMI intervention, 0.96 (95% CI: 0.81, 1.10) under the physical activity intervention, and 0.92 (95% CI: 0.78, 1.06) under the joint intervention. Interventions on BMI and physical activity may have a modest impact on the risk of adult-onset asthma in this population of US women.
PMCID: PMC3864713  PMID: 24107616
asthma; body mass index; g-formula; hypothetical interventions; physical activity
2.  Vitamin D and Gestational Diabetes Mellitus 
Current diabetes reports  2014;14(1):451.
Gestational diabetes mellitus (GDM) complicates 7–14% of pregnancies in the United States. Vitamin D deficiency also is common in pregnancy. Emerging evidence suggests that Vitamin D administration can improve insulin sensitivity and glucose tolerance, but whether vitamin D supplementation can prevent GDM is unknown. Observational studies provide conflicting evidence as to whether low serum 25-hydroxyvitmain D (25(OH)D) levels are associated with GDM. Two recent systematic reviews concluded that vitamin D deficiency is associated with a higher risk of GDM. However, these reviews are limited by the observational and diverse nature of the included studies. Of greatest concern is the inability to understand how important confounding variables such as race/ethnicity and adiposity might affect the association. Randomized controlled trial data remain limited but are critical to understanding whether supplementation with vitamin D beyond what is contained in routine prenatal vitamins will prevent GDM or improve glucose tolerance for women with GDM.
PMCID: PMC3895371  PMID: 24277676
Vitamin D; 25-hydroxyvitamin D; pregnancy; gestational diabetes mellitus; GDM; gestational diabetes
3.  High shape concerns predicts becoming obese, binge drinking, and drug use among adolescent and young adult males 
JAMA pediatrics  2014;168(1):34-39.
Relatively little is known about the prevalence of body shape concerns and disordered eating among males, and their relations to subsequent adverse outcomes.
To investigate whether males with eating and shape concern-related psychopathology are more likely to become obese, start using drugs, drinking frequently, or develop high depressive symptoms.
Prospective cohort study
Growing Up Today Study data collected by questionnaire every 12–36 months.
5527 males, aged 12–18 in 1999, from across the United States.
Main outcome measures
Becoming obese, starting to use drugs, starting to binge drink at least monthly, and developing high depressive symptoms.
Between 1999 and 2011, in at least one year of study, 9.2% reported high concerns with muscularity but no bulimic behaviors; 2.4% high concerns with muscularity and used supplements, growth hormone or steroids to achieve their desired physique; 2.5% high concerns with thinness but no bulimic behaviors; 6.3% high concerns with both thinness and muscularity; 0.8% had partial or full criteria bulimia nervosa (BN) or purging disorder (PD); 2.9% had partial or full criteria binge eating disorder (BED); and 31% infrequently engaged in binge eating or purging or overeating without a loss of control. BN, PD, and BED were not associated with an increased risk of any outcomes. However, independent of age and BMI, boys with high concerns with thinness, but not muscularity, were more likely to develop high depressive symptoms (Odds ratio (OR)=2.7, 95% confidence interval (CI) 1.4–5.4). Boys with high concerns with muscularity and thinness were more likely than their peers to using drugs (OR=2.1, 95% CI 1.3–3.5) and boys with high muscularity concerns who used supplements and other products to enhance physique were more likely to start binge drinking frequently (OR=2.1, 95% CI 1.6–2.7) and using drugs (OR=2.2, 95% CI 1.5–3.1).
High concerns with muscularity are relatively common among adolescent and young adult males.
Males with concerns with muscularity who use potentially unhealthy products to improve their physique are at increased risk of adverse outcomes, but may not be recognized by their clinicians as having a weight-related disorder because of the gender-specific presentation.
PMCID: PMC3947325  PMID: 24190655
Eating disorders; adolescents; supplements; muscularity; epidemiology; substance use
4.  Temporal Trends in Emergency Department Visits for Bronchiolitis in the United States, 2006-2010 
To examine temporal trends in emergency departments (ED) visits for bronchiolitis among US children between 2006 and 2010.
Serial, cross-sectional analysis of the Nationwide Emergency Department Sample, a nationally-representative sample of ED patients. We used ICD-9-CM code 466.1 to identify children <2 years of age with bronchiolitis. Primary outcome measures were rate of bronchiolitis ED visits, hospital admission rate, and ED charges.
Between 2006 and 2010, weighted national discharge data included 1,435,110 ED visits with bronchiolitis. There was a modest increase in the rate of bronchiolitis ED visits, from 35.6 to 36.3 per 1000 person-years (2% increase; Ptrend=0.008), due to increases in the ED visit rate among children from 12 months to 23 months (24% increase; Ptrend<0.001). By contrast, there was a significant decline in the ED visit rate among infants (4% decrease; Ptrend<0.001) Although unadjusted admission rate did not change between 2006 and 2010 (26% in both years), admission rate declined significantly after adjusting for potential patient- and ED-level confounders (adjusted OR for comparison of 2010 with 2006, 0.84; 95%CI, 0.76-0.93; P<0.001). Nationwide ED charges for bronchiolitis increased from $337 million to $389 million (16% increase; Ptrend<0.001), adjusted for inflation. This increase was driven by a rise in geometric mean of ED charges per case from $887 to $1059 (19% increase; Ptrend<0.001).
Between 2006 and 2010, we found a divergent temporal trend in the rate of bronchiolitis ED visits by age group. Despite a significant increase in associated ED charges, ED-associated hospital admission rates for bronchiolitis significantly decreased over this same period.
PMCID: PMC3984903  PMID: 23934206
bronchiolitis; emergency department; incidence; hospitalization; charge
5.  Do Emergency Department Patients Receive a Pathological Diagnosis? A Nationally-Representative Sample 
Understanding the cause of patients’ symptoms often requires identifying a pathological diagnosis. A single-center study found that many patients discharged from the emergency department (ED) do not receive a pathological diagnosis. We analyzed 17 years of data from the National Hospital Ambulatory Medical Care Survey (NHAMCS) to identify the proportion of patients who received a pathological diagnosis at ED discharge. We hypothesized that many patients do not receive a pathological diagnosis, and that the proportion of pathological diagnoses increased between 1993 and 2009.
Using the NHAMCS data from 1993–2009, we analyzed visits of patients age ≥18 years, discharged from the ED, who had presented with the three most common chief complaints: chest pain, abdominal pain, and headache. Discharge diagnoses were coded as symptomatic versus pathological based on a pre-defined coding system. We compared weighted annual proportions of pathological discharge diagnoses with 95% CIs and used logistic regression to test for trend.
Among 299,919 sampled visits, 44,742 met inclusion criteria, allowing us to estimate that there were 164 million adult ED visits presenting with the three chief complaints and then discharged home. Among these visits, the proportions with pathological discharge diagnosis were 55%, 71%, and 70% for chest pain, abdominal pain, and headache, respectively. The total proportion of those with a pathological discharge diagnosis decreased between 1993 and 2009, from 72% (95% CI, 69–75%) to 63% (95% CI, 59–66%). In the multivariable logistic regression model, those more likely to receive pathological diagnoses were females, African-American as compared to Caucasian, and self-pay patients. Those more likely to receive a symptomatic diagnosis were patients aged 30–79 years, with visits to EDs in the South or West regions, and seen by a physician in the ED.
In this analysis of a nationally-representative database of ED visits, many patients were discharged from the ED without a pathological diagnosis that explained the likely cause of their symptoms. Despite advances in diagnostic testing, the proportion of pathological discharge diagnoses decreased. Future studies should investigate reasons for not providing a pathological diagnosis and how this may affect clinical outcomes.
PMCID: PMC4307726
9.  Guidelines for the Diagnosis and Management of Food Allergy in the United States 
Food allergy is an important public health problem that affects children and adults and may be increasing in prevalence. Despite the risk of severe allergic reactions and even death, there is no current treatment for food allergy: the disease can only be managed by allergen avoidance or treatment of symptoms. The diagnosis and management of food allergy also may vary from one clinical practice setting to another. Finally, because patients frequently confuse nonallergic food reactions, such as food intolerance, with food allergies, there is an unfounded belief among the public that food allergy prevalence is higher than it truly is. In response to these concerns, the National Institute of Allergy and Infectious Diseases, working with 34 professional organizations, federal agencies, and patient advocacy groups, led the development of clinical guidelines for the diagnosis and management of food allergy. These Guidelines are intended for use by a wide variety of health care professionals, including family practice physicians, clinical specialists, and nurse practitioners. The Guidelines include a consensus definition for food allergy, discuss comorbid conditions often associated with food allergy, and focus on both IgE-mediated and non-IgE-mediated reactions to food. Topics addressed include the epidemiology, natural history, diagnosis, and management of food allergy, as well as the management of severe symptoms and anaphylaxis. These Guidelines provide 43 concise clinical recommendations and additional guidance on points of current controversy in patient management. They also identify gaps in the current scientific knowledge to be addressed through future research.
PMCID: PMC4241964  PMID: 21134576
food; allergy; anaphylaxis; diagnosis; disease management; guidelines
10.  DASH for asthma: A pilot study of the DASH diet in not-well-controlled adult asthma⋆ 
Contemporary clinical trials  2013;35(2):55-67.
This pilot study aims to provide effect size confidence intervals, clinical trial and intervention feasibility data, and procedural materials for a full-scale randomized controlled trial that will determine the efficacy of Dietary Approaches to Stop Hypertension (DASH) as adjunct therapy to standard care for adults with uncontrolled asthma. The DASH diet encompasses foods (e.g., fresh fruit, vegetables, and nuts) and antioxidant nutrients (e.g., vitamins A, C, E, and zinc) with potential benefits for persons with asthma, but it is unknown whether the whole diet is beneficial. Participants (n = 90) will be randomized to receive usual care alone or combined with a DASH intervention consisting of 8 group and 3 individual sessions during the first 3 months, followed by at least monthly phone consultations for another 3 months. Follow-up assessments will occur at 3 and 6 months. The primary outcome measure is the 7-item Juniper Asthma Control Questionnaire, a validated composite measure of daytime and nocturnal symptoms, activity limitations, rescue medication use, and percentage predicted forced expiratory volume in 1 second. We will explore changes in inflammatory markers important to asthma pathophysiology (e.g., fractional exhaled nitric oxide) and their potential to mediate the intervention effect on disease control. We will also conduct pre-specified subgroup analyses by genotype (e.g., polymorphisms on the glutathione S transferase gene) and phenotype (e.g., atopy, obesity). By evaluating a dietary pattern approach to improving asthma control, this study could advance the evidence base for refining clinical guidelines and public health recommendations regarding the role of dietary modifications in asthma management.
PMCID: PMC4217513  PMID: 23648395
DASH; Dietary pattern; Asthma; Lung function; Asthma Control Questionnaire
11.  Apnea in Children Hospitalized With Bronchiolitis 
Pediatrics  2013;132(5):e1194-e1201.
To identify risk factors for inpatient apnea among children hospitalized with bronchiolitis.
We enrolled 2207 children, aged <2 years, hospitalized with bronchiolitis at 16 sites during the winters of 2007 to 2010. Nasopharyngeal aspirates (NPAs) were obtained on all subjects, and real-time polymerase chain reaction was used to test NPA samples for 16 viruses. Inpatient apnea was ascertained by daily chart review, with outcome data in 2156 children (98%). Age was corrected for birth <37 weeks. Multivariable logistic regression was performed to identify independent risk factors for inpatient apnea.
Inpatient apnea was identified in 108 children (5%, 95% confidence interval [CI] 4%–6%). Statistically significant, independent predictors of inpatient apnea included: corrected ages of <2 weeks (odds ratio [OR] 9.67) and 2 to 8 weeks (OR 4.72), compared with age ≥6 months; birth weight <2.3 kg (5 pounds; OR 2.15), compared with ≥3.2 kg (7 pounds); caretaker report of previous apnea during this bronchiolitis episode (OR 3.63); preadmission respiratory rates of <30 (OR 4.05), 30 to 39 (OR 2.35) and >70 (OR 2.26), compared with 40 to 49; and having a preadmission room air oxygen saturation <90% (OR 1.60). Apnea risk was similar across the major viral pathogens.
In this prospective, multicenter study of children hospitalized with bronchiolitis, inpatient apnea was associated with younger corrected age, lower birth weight, history of apnea, and preadmission clinical factors including low or high respiratory rates and low room air oxygen saturation. Several bronchiolitis pathogens were associated with apnea, with similar apnea risk across the major viral pathogens.
PMCID: PMC3813402  PMID: 24101759
apnea; bronchiolitis; viral infections; infants; hospitalization
13.  Childhood Asthma Hospitalizations in the United States, 2000-2009 
The Journal of pediatrics  2013;163(4):1127-1133.e3.
To examine temporal trends in the US incidence of childhood asthma hospitalizations, inhospital mortality, mechanical ventilation use, and hospital charges between 2000 and 2009.
Study design
A serial, cross-sectional analysis of a nationally-representative sample of children hospitalized with acute asthma. The Kids Inpatient Database was used to identify children <18 years of age with asthma by International Classification of Diseases, Ninth Revision, Clinical Modification code 493.xx. Outcome Measures were asthma hospitalization incidence, in-hospital mortality, mechanical ventilation use, and hospital charges. We examined temporal trends of each outcome, accounting for sampling weights. Hospital charges were adjusted for inflation to 2009 US dollars.
The four separated years (2000, 2003, 2006, and 2009) of national discharge data included 592 805 weighted discharges with asthma. Between 2000 and 2009, asthma hospitalization incidence decreased from 21.1 to 18.4 per 10 000 person-years among all US children (13% decrease; Ptrend<.001). Mortality declined significantly after adjusting for confounders (OR for comparison of 2009 with 2000, 0.37; 95%CI, 0.17-0.79). By contrast, there was an increase in mechanical ventilation use (0.8% to 1.0%; 28% increase; Ptrend<.001). Nationwide hospital charges also increased from $1.27 billion to $1.59 billion (26% increase; Ptrend<.001); this increase was driven by a rise in the geometric mean of hospital charges per discharge, from $5940 to $8410 (42% increase; Ptrend<.001).
Between 2000 and 2009, we found significant declines in asthma hospitalization and in-hospital mortality among US children. By contrast, mechanical ventilation use and hospital charges for asthma significantly increased over this same period.
PMCID: PMC3786053  PMID: 23769497
asthma; children; trends; hospitalization; mechanical ventilation; mortality; length of stay; hospital charge
14.  The Emergency Department Safety Assessment and Follow-up Evaluation (ED-SAFE): Method and Design Considerations 
Contemporary clinical trials  2013;36(1):14-24.
Due to the concentration of individuals at-risk for suicide, an emergency department visit represents an opportune time for suicide risk screening and intervention.
The Emergency Department Safety Assessment and Follow-up Evaluation (ED-SAFE) uses a quasi-experimental, interrupted time series design to evaluate whether (1) a practical approach to universally screening ED patients for suicide risk leads to improved detection of suicide risk and (2) a multi-component intervention delivered during and after the ED visit improves suicide-related outcomes.
This paper summarizes the ED-SAFE’s study design and methods within the context of considerations relevant to effectiveness research in suicide prevention and pertinent human participants concerns. 1,440 suicidal individuals, from 8 general ED’s nationally will be enrolled during three sequential phases of data collection (480 individuals/phase): (1) Treatment as Usual; (2) Universal Screening; and (3) Intervention. Data from the three phases will inform two separate evaluations: Screening Outcome (Phases 1 and 2) and Intervention (Phases 2 and 3). Individuals will be followed for 12 months. The primary study outcome is a composite reflecting completed suicide, attempted suicide, aborted or interrupted attempts, and implementation of rescue procedures during an outcome assessment.
While ‘classic’ randomized control trials (RCT) are typically selected over quasi-experimental designs, ethical and methodological issues may make an RCT a poor fit for complex interventions in an applied setting, such as the ED. ED-SAFE represents an innovative approach to examining the complex public health issue of suicide prevention through a multiphase, quasi-experimental design embedded in ‘real world’ clinical settings.
PMCID: PMC3979300  PMID: 23707435
suicide; research methods; mental health; emergency department
15.  Are operating room nurses at higher risk of severe persistent asthma? 
To assess the associations between operating room (OR) nursing, a category of health care workers at high risk of exposure to various inhaled agents, and asthma severity/control among women with asthma.
The level of severity/control in nurses with prevalent doctor-diagnosed asthma in 1998/2000 was compared, using nominal logistic regression, in OR nursing (n=69) and administrative nursing (n=546) from the US Nurses’ Health Study for whom detailed information on asthma and nursing employment status was available.
We observed a significant association between OR nursing, compared to administrative nursing, and severe persistent asthma (adjusted odds ratio 2.48, 95%CI 1.06–5.77).
Our findings suggest that nurses working in the operating room are at a higher risk of severe persistent asthma. Further studies with detailed estimates of occupational exposures, especially to disinfectant/cleaning agents, are warranted.
PMCID: PMC3740047  PMID: 23887704
operating room nurse; occupation; asthma severity; epidemiology
16.  Acute Respiratory Distress Syndrome After Spontaneous Intracerebral Hemorrhage 
Critical care medicine  2013;41(8):1992-2001.
Acute respiratory distress syndrome develops commonly in critically ill patients in response to an injurious stimulus. The prevalence and risk factors for development of acute respiratory distress syndrome after spontaneous intracerebral hemorrhage have not been reported. We sought to determine the prevalence of acute respiratory distress syndrome after intracerebral hemorrhage, characterize risk factors for its development, and assess its impact on patient outcomes.
Retrospective cohort study at two academic centers.
We included consecutive patients presenting from June 1, 2000, to November 1, 2010, with intracerebral hemorrhage requiring mechanical ventilation. We excluded patients with age less than 18 years, intracerebral hemorrhage secondary to trauma, tumor, ischemic stroke, or structural lesion; if they required intubation only during surgery; if they were admitted for comfort measures; or for a history of immunodefciency.
Measurements and Main Results
Data were collected both prospectively as part of an ongoing cohort study and by retrospective chart review. Of 1,665 patients identified by database query, 697 met inclusion criteria. The prevalence of acute respiratory distress syndrome was 27%. In unadjusted analysis, high tidal volume ventilation was associated with an increased risk of acute respiratory distress syndrome (hazard ratio, 1.79 [95% CI, 1.13–2.83]), as were male sex, RBC and plasma transfusion, higher fluid balance, obesity, hypoxemia, acidosis, tobacco use, emergent hematoma evacuation, and vasopressor dependence. In multivariable modeling, high tidal volume ventilation was the strongest risk factor for acute respiratory distress syndrome development (hazard ratio, 1.74 [95% CI, 1.08–2.81]) and for inhospital mortality (hazard ratio, 2.52 [95% CI, 1.46–4.34]).
Development of acute respiratory distress syndrome is common after intubation for intracerebral hemorrhage. Modifiable risk factors, including high tidal volume ventilation, are associated with its development and in-patient mortality.
PMCID: PMC3752686  PMID: 23760151
acute lung injury; hemorrhagic stroke; mechanical ventilation; tidal volume; ventilator-induced lung injury
17.  Evaluating Current Patterns of Assessment for Self-Harm in Emergency Departments, A Multicenter Study 
To describe self-harm assessment practices in U.S. emergency departments (EDs) and to identify predictors of being assessed.
This was a prospective observational cohort study of adults presenting to eight U.S. EDs. A convenience sample of adults presenting to the EDs during covered research shifts was entered into a study log. Self-harm assessment was defined as ED documentation of suicide attempt, suicidal ideation, or non-suicidal self-injury thoughts, behaviors, or both. Institution characteristics were compared relative to percentage assessed. To identify predictive patient characteristics, multivariable generalized linear models were created controlling for weekend presentation, time of presentation, age, sex, and race and ethnicity.
Among 94,354 charts, self-harm assessment ranged from 3.5% to 31%, except for one outlying site at 95%. Overall, 26% were assessed (11% excluding the outlying site). Current self-harm was present in 2.7% of charts. Sites with specific self-harm assessment policies had higher assessment rates. In the complete model, adjusted risk ratios (aRR) for assessment included age ≥ 65 years (0.56, 95% CI = 0.35 to 0.92) and male sex (1.17, 95% CI = 1.10 to 1.26). There was an interaction between these variables in the smaller model (excluding outlying site), with males <65 years of age being more likely to be assessed (aRR 1.14, 95% CI = 1.02 to 1.37).
Emergency department assessment of self-harm was highly variable among institutions. Presence of specific assessment policies was associated with higher assessment rates. Assessment varied based upon patient characteristics. The identification of self-harm in 2.7% of ED patients indicates that a substantial proportion of current risk of self-harm may go unidentified, particularly in certain patient groups.
PMCID: PMC3775284  PMID: 24033624
18.  Trends in Bronchiolitis Hospitalizations in the United States, 2000–2009 
Pediatrics  2013;132(1):28-36.
To examine temporal trend in the national incidence of bronchiolitis hospitalizations, use of mechanical ventilation, and hospital charges between 2000 and 2009.
We performed a serial, cross-sectional analysis of a nationally representative sample of children hospitalized with bronchiolitis. The Kids Inpatient Database was used to identify children <2 years of age with bronchiolitis by International Classification of Diseases, Ninth Revision, Clinical Modification code 466.1. Primary outcome measures were incidence of bronchiolitis hospitalizations, mechanical ventilation (noninvasive or invasive) use, and hospital charges. Temporal trends were evaluated accounting for sampling weights.
The 4 separated years (2000, 2003, 2006, and 2009) of national discharge data included 544 828 weighted discharges with bronchiolitis. Between 2000 and 2009, the incidence of bronchiolitis hospitalization decreased from 17.9 to 14.9 per 1000 person-years among all US children aged <2 years (17% decrease; Ptrend < .001). By contrast, there was an increase in children with high-risk medical conditions (5.9%–7.9%; 34% increase; Ptrend < .001) and use of mechanical ventilation (1.9%–2.3%; 21% increase; Ptrend = .008). Nationwide hospital charges increased from $1.34 billion to $1.73 billion (30% increase; Ptrend < .001); this increase was driven by a rise in the geometric mean of hospital charges per case from $6380 to $8530 (34% increase; Ptrend < .001).
Between 2000 and 2009, we found a significant decline in bronchiolitis hospitalizations among US children. By contrast, use of mechanical ventilation and hospital charges for bronchiolitis significantly increased over this same period.
PMCID: PMC3691534  PMID: 23733801
bronchiolitis; trends; hospitalization; incidence; mortality; hospital charge
19.  Characteristics of United States Emergency Departments that Routinely Perform Alcohol Risk Screening and Counseling for Patients Presenting with Drinking–related Complaints 
Emergency department (ED) screening and counseling for alcohol misuse have been shown to reduce at-risk drinking. However, barriers to more widespread adoption of this service remain unclear.
We performed a secondary analysis of a nationwide survey of 277 EDs to determine the proportion of EDs that routinely perform alcohol screening and counseling among patients presenting with alcohol-related complaints and to identify potential institutional barriers and facilitators to routine screening and counseling. The survey was randomly mailed to 350 EDs sampled from the 2007 National Emergency Department Inventory (NEDI), with 80% of ED medical directors responding after receiving the mailing or follow-up fax/email. The survey asked about a variety of preventive services and ED directors’ opinions regarding perceived barriers to offering preventive services in their EDs.
Overall, only 27% of all EDs and 22% of Level I/II trauma center EDs reported routinely screening and counseling patients presenting with drinking-related complaints. Rates of routine screening and counseling were similar across geographic areas, crowding status, and urban-rural status. EDs that performed routine screening and counseling often offered other preventive services, such as tobacco cessation (P<0.01) and primary care linkage (P=0.01). EDs with directors who expressed concern about increased financial costs to the ED, inadequate follow-up, and diversion of nurse/physician time all had lower rates of screening and counseling and also more frequently reported lacking the perceived capacity to perform routine counseling and screening. Among EDs that did not routinely perform alcohol screening and counseling, more crowded than non-crowded (P<0.01) and more metro than rural (P<0.01) EDs reported lacking the capacity to perform routine screening and counseling. The capacity to perform routine screening also decreased as ED visit volume increased (P=0.04).
To increase routine alcohol screening and counseling for patients presenting with alcohol-related complaints, ED directors’ perceived barriers related to an ED’s capacity to perform screening, such as limited financial and staff resources, should be addressed, as should directors’ concerns regarding the implementation of preventive health services in EDs. Uniform reimbursement methods should be used to increase ED compensation for performing this important and effective service.
PMCID: PMC4100850  PMID: 25035750
20.  Availability of Insurance Linkage Programs in U.S. Emergency Departments 
As millions of uninsured citizens who use emergency department (ED) services are now eligible for health insurance under the Affordable Care Act, the ED is ideally situated to facilitate linkage to insurance. Forty percent of U.S. EDs report having an insurance linkage program. This is the first national study to examine the characteristics of EDs that offer or do not offer these programs.
This was a secondary analysis of data from the National Survey for Preventive Health Services in U.S. EDs conducted in 2008–09. We compared EDs with and without insurance programs across demographic and operational factors using univariate analysis. We then tested our hypotheses using multivariable logistic regression. We also further examined program capacity and priority among the sub-group of EDs with no insurance linkage program.
After adjustment, ED-insurance linkage programs were more likely to be located in the West (RR= 2.06, 95% CI = 1.33 – 2.72). The proportion of uninsured patients in an ED, teaching hospital status, and public ownership status were not associated with insurance linkage availability. EDs with linkage programs also offer more preventive services (RR = 1.87, 95% CI = 1.37–2.35) and have greater social worker availability (RR = 1.71, 95% CI = 1.12–2.33) than those who do not. Four of five EDs with a patient mix of ≥25% uninsured and no insurance linkage program reported that they could not offer a program with existing staff and funding.
Availability of insurance linkage programs in the ED is not associated with the proportion of uninsured patients served by an ED. Policy or hospital-based interventions to increase insurance linkage should first target the 27% of EDs with high rates of uninsured patients that lack adequate program capacity. Further research on barriers to implementation and cost effectiveness may help to facilitate increased adoption of insurance linkage programs.
PMCID: PMC4100863  PMID: 25035763
21.  Prospective Study of Vitamin D Status at Initiation of Care in Critically Ill Surgical Patients and Risk of 90-Day Mortality 
Critical care medicine  2014;42(6):1365-1371.
1) To characterize vitamin D status at initiation of critical care in surgical ICU patients and 2) to determine whether this vitamin D status is associated with the risk of prolonged hospital length of stay, 90-day readmission, and 90-day mortality.
Prospective cohort study.
A teaching hospital in Boston, MA.
Hundred surgical ICU patients.
Measurements and Main Results
Mean (± SD) serum total 25-hydroxyvitamin D and 1,25-dihydroxyvitamin D levels were 17 ± 8 ng/mL and 32 ± 19 pg/mL, respectively. Mean calculated bioavailable 25-hydroxyvitamin D and 1,25-dihydroxyvitamin D were 2.5 ± 2.0 ng/mL and 6.6 ± 5.3 pg/mL, respectively. Receiver- operating characteristic curve analysis demonstrated that all of four vitamin D measures predicted the three clinical outcomes; total 25-hydroxyvitamin D was not inferior to the other measures. Median (interquartile range) hospital length of stay was 11 days (8–19 d). Poisson regression analysis, adjusted for biologically plausible covariates, demonstrated an association of total 25-hydroxyvitamin D with hospital length of stay (incident rate ratio per 1 ng/mL, 0.98; 95% CI, 0.97–0.98). The 90-day readmission and mortality rates were 24% and 22%, respectively. Even after adjustment for biologically plausible covariates, there remained significant associations of total 25-hydroxyvitamin D with readmission (odds ratio per 1 ng/mL, 0.84; 95% CI, 0.74–0.95) and mortality (odds ratio per 1 ng/mL, 0.84; 95% CI, 0.73–0.97).
Serum 25-hydroxyvitamin D levels within 24 hours of ICU admission may identify patients at high risk for prolonged hospitalization, readmission, and mortality. Randomized trials are needed to assess whether vitamin D supplementation can improve these clinically relevant outcomes in surgical ICU patients.
PMCID: PMC4064717  PMID: 24557421
25-hydroxyvitamin; bioavailable 25-hydroxyvitamin; intensive care unit; mortality; vitamin D
22.  Prevalence and phenotypic characterization of Enterococcus spp. isolated from food in Brazil 
Brazilian Journal of Microbiology  2014;45(1):111-115.
We evaluated the frequency of enterococci from food and found 95.2% of positivity, being E. faecium and E. faecalis the most frequent species. High-level streptomycin resistance was observed, as well as gelatinase and hemolysis activity, showing the potential role of environmental strains as reservoir of virulence and resistance traits.
PMCID: PMC4059285  PMID: 24948921
Enterococcus spp.; food; antimicrobial resistance
23.  Association Between Preoperative 25-Hydroxyvitamin D Level and Hospital-Acquired Infections Following Roux-en-Y Gastric Bypass Surgery 
JAMA surgery  2014;149(2):112-118.
Postoperative hospital-acquired infections (HAIs) may result from disruption of natural barrier sites. Recent studies have linked vitamin D status and barrier site integrity.
To investigate the association between preoperative vitamin D status and the risk for HAIs.
A retrospective analysis was performed using propensity score methods to construct a matched-pairs cohort to reduce baseline differences between patients with 25-hydroxyvitamin D (25[OH]D) levels less than 30 ng/mL vs 30 ng/mL or greater. Multivariable logistic regression analysis was then performed to examine the association between 25(OH)D levels and HAIs while adjusting for additional perioperative factors. Locally weighted scatterplot smoothing was used to depict the relationship between increasing 25(OH)D levels and the risk for HAIs. This study was conducted in a single, teaching hospital in Boston, Massachusetts, and involved 770 gastric bypass surgery patients between January 1, 2007, and December 31, 2011.
Preoperative 25(OH)D levels.
Association between preoperative 25(OH)D levels and the risk for postoperative HAIs.
The risk for HAIs was 3-fold greater (adjusted odds ratio, 3.05; 95%CI, 1.34–6.94) in patients with 25(OH)D levels less than 30 ng/mL vs 30 ng/mL or greater. Further adjustment for additional perioperative factors did not materially change this association. Locally weighted scatterplot smoothing analysis depicted a near inverse linear relationship between vitamin D status and the risk for HAIs for 25(OH)D levels around 30 ng/mL.
In our patient cohort, a significant inverse association was observed between preoperative 25(OH)D levels and the risk for HAIs. These results suggest that preoperative 25(OH)D levels may be a modifiable risk factor for postoperative nosocomial infections. Prospective studies must determine whether there is a potential benefit to preoperative optimization of vitamin D status.
PMCID: PMC4062917  PMID: 24284777
24.  Single-nucleotide polymorphisms of allergy-related genes and risk of adult glioma 
Journal of neuro-oncology  2013;113(2):229-238.
Previous studies have shown an inverse association between allergies and glioma risk; however, results for associations between single nucleotide polymorphisms (SNPs) of allergy-related genes and glioma risk have been inconsistent and restricted to a small number of SNPs. The objective of this study was to examine the association between 166 SNPs of 21 allergy-related genes and glioma risk in a nested case-control study of participants from three large US prospective cohort studies. Blood collection took place between 1982 and 1994 among the 562 included Caucasian participants (143 cases and 419 matched controls) prior to case diagnosis. Custom Illumina assay chips were used for genotyping. Logistic regression analyses, controlling for age and study cohort, were used to determine associations between each SNP and glioma risk. Statistically significant associations were found between rs2494262 and rs2427824 of the FCER1A gene, which encodes the alpha chain of the high affinity immunoglobulin E receptor, and glioma risk (nominal trend p-values 0.01 and 0.03, respectively). Significant associations were also found between SNPs in IL10, ADAM33, NOS1 and IL4R and glioma risk; however, these were not corrected for multiple comparisons and need to be interpreted with caution. Our findings with FCER1A SNPs provide further support for the link between allergies and risk of glioma.
PMCID: PMC3679351  PMID: 23525950
Brain tumors; glioma; allergies; single-nucleotide polymorphisms; cohort studies
25.  Emergency department visits for acute asthma by adults who ran out of their inhaled medications 
Allergy and Asthma Proceedings  2014;35(3):e42-e50.
This study was designed to determine the percentage of asthma-related emergency department (ED) visits made by patients who recently ran out of their inhaled short-acting beta-agonists or inhaled corticosteroids and to characterize this understudied patient population. A secondary analysis was performed of data from four ED-based multicenter studies of acute asthma during 1996–1998 (n = 64 EDs). In each study, consecutive adult patients, aged 18–54 years, with acute asthma underwent a structured interview that assessed running out of inhaled medications. The analytic cohort comprised 1095 adults. Overall, 324 patients (30%; 95% confidence interval [CI], 27–32%) ran out of either of their inhaled beta-agonists or inhaled corticosteroids during the week before their index ED visit; 311 (28%; 95% CI, 26–31%) ran out of inhaled beta-agonists per se. Among a subset of 518 patients on inhaled corticosteroids, 55 patients (11%; 95% CI, 8–14%) ran out of inhaled corticosteroids. In the multivariable model, predictors of running out of an asthma medication were male sex, non-Hispanic black race, Hispanic ethnicity, no insurance, lower household income, and use of EDs as the preferred source of asthma prescriptions (all p < 0.05). Among patients who ran out of medications, 49% (95% CI, 43–55%) ran out of inhaled beta-agonists and 72% (95% CI, 58–84%) ran out of inhaled corticosteroids, before onset of their acute asthma symptoms. In 1095 adult ED patients with acute asthma, we found that 30% ran out of their inhaled asthma medications before the ED visit. Asthma patients who ran out of medications had sociodemographic characteristics that may help with identification of preventable ED visits. Multifaceted strategies needed to ensure optimal use of inhaled medications are warranted.
PMCID: PMC4012130  PMID: 24801458
Acute asthma; emergency department; ethnicity; inhaled bronchodilator; inhaled corticosteroids; multicenter study; nonadherence; race; socioeconomic status

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