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Pediatric emergency care in New York City during the COVID-19 pandemic shutdown and reopening periods

Liang, Tian; Chamdawala, Haamid S; Tay, Ee Tein; Chao, Jennifer; Waseem, Muhammad; Lee, Horton; Mortel, David; Agoritsas, Konstantinos; Teo, Hugo O; Meltzer, James A
OBJECTIVE:New York City (NYC) is home to the largest public healthcare system in the United States and was an early epicenter of coronavirus disease 2019 (COVID-19) infections. This system serves as the safety net for underserved and marginalized communities disproportionately affected by the pandemic. Prior studies reported substantial declines in pediatric emergency department (ED) volume during the initial pandemic surge, but few describe the ongoing impact of COVID-19 throughout the year. We evaluated the characteristics of pediatric ED visits to NYC public hospitals during the pandemic lockdown and reopening periods of 2020 compared to the prior year. METHODS:Retrospective cross-sectional analysis of pediatric ED visits from 11 NYC public hospitals from January 2019-December 2020. Visit demographics, throughput times, and diagnosis information during the early (3/7/20-6/7/20) and late (6/8/20-12/31/20) pandemic periods coinciding with the New York State of emergency declaration (3/7/20) and the first reopening date (6/7/20) were compared to similar time periods in 2019. Findings were correlated with key pandemic shutdown and reopening events. RESULTS:There was a 47% decrease in ED volume in 2020 compared to 2019 (125,649 versus 238,024 visits). After reopening orders began in June 2020, volumes increased but peaked at <60% of 2019 volumes. Admission rates, triage acuity, and risk of presenting with a serious medical illness were significantly higher in 2020 versus 2019 (P < 0.001). Time-to-provider times decreased however provider-to-disposition times increased during the pandemic (P < 0.001). Infectious and asthma diagnoses declined >70% during the pandemic in contrast to the year prior. After reopening periods began, penetrating traumatic injuries significantly increased compared to 2019 [+34%, Relative Risk: 3.2 (2.6, 3.8)]. CONCLUSIONS:NYC public hospitals experienced a sharp decrease in pediatric volume but an increase in patient acuity during both the initial pandemic surge and through the reopening periods. As COVID-19 variants emerge, the threat of the current pandemic expanding remains. Understanding its influence on pediatric ED utilization can optimize resource allocation and ensure equitable care for future surge events.
PMID: 35397354
ISSN: 1532-8171
CID: 5205032

Recent Estimates of Survival in Patients with Advanced Non-Small Cell Lung Cancer (NSCLC) in the US (2010-2020) [Meeting Abstract]

Kalilani, L; Chao, J; Hogea, C; Stojadinovic, A; Giove, T J; Sun, X; Aziez, A; Velcheti, V
Objectives: Despite availability of new treatments, the prognosis of lung cancer remains poor. This study aims to provide recent estimates of survival in patients with advanced non-small cell lung cancer (NSCLC) in the US.
Method(s): The survival of patients with advanced NSCLC was estimated using two US databases together covering 2010-2020. The study included patients with stage III or IV NSCLC diagnosed between 2010-2016 in the Surveillance, Epidemiology, and End Results Program (SEER) database, and patients with stage IIIB, IIIC or IV NSCLC, diagnosed between 2017-2020, without known oncogenic driver mutations who had completed >=4 cycles of 1L treatment (restricted to platinum-based combinations, immuno-oncology monotherapy, or ipilimumab/nivolumab) in the Flatiron Health database, a US Oncology Electronic Medical Record database. Overall survival (OS) was defined as time from diagnosis of stage III or IV NSCLC to death or to date of last confirmed activity.
Result(s): A total of 49,298 and 133,395 patients with stage III and IV diagnosis respectively were identified in SEER. The 1-, 3- and 5-year OS for patients with Stage III disease were 55.1%, 26.3% and 17.5%, and for stage IV disease were 25.8%, 7.4% and 4.0%, respectively. The Flatiron database had 1,045 patients with stage IIIB, 130 patients with stage IIIC and 3,210 patients with stage IV disease at diagnosis. The 1- and 3-year OS for stage IIIB/IIIC disease were 72.5% and 36.4%, and for patients with stage IV disease were 65.9% and 24.6%, respectively.
Conclusion(s): Despite differences in study population characteristics between the two databases, the study shows that mortality in patients with advanced NSCLC remains high, underscoring the need for continued efforts to identify novel treatments and synergetic treatment combinations to improve patient outcomes.
ISSN: 1524-4733
CID: 5138662

Prevalence of Bacteremia in Febrile Patients With Sickle Cell Disease: Meta-Analysis of Observational Studies

Bala, Natasha; Chao, Jennifer; John, Delna; Sinert, Richard
OBJECTIVE:Pneumococcal vaccination has decreased the bacteremia rate in both the general pediatric and sickle cell disease (SCD) populations. Despite this decrease, and an increasing concern for antibiotic resistance, it remains standard practice to obtain blood cultures and administer antibiotics in all febrile (>38.5°C) patients with SCD. We conducted a systematic review and meta-analysis of the available studies of the prevalence of bacteremia in febrile patients with SCD. METHODS:We searched the medical literature up to November 2018 in PUBMED, EMBASE, and Web of Science with terms epidemiology, prevalence, bacteremia, and sickle cell anemia. We only included studies with patients after 2000, when the pneumococcal 7-valent conjugate (PCV7) vaccine became widely available. The prevalence of bacteremia [95% confidence interval (CI)] was calculated by dividing the number of positive blood cultures by the number of febrile episodes. The I statistic measured heterogeneity between prevalence estimates. Bias in our studies was quantified by the Newcastle-Ottawa Quality Assessment Scale. RESULTS:Our search identified 228 citations with 10 studies meeting our inclusion/exclusion criteria. The weighted prevalence of bacteremia across all studies was 1.9% (95% CI, 1.22%-2.73%), and for Streptococcus pneumoniae bacteremia, it was 0.31% (95% CI, 0.16%-0.50%). Risks for bacteremia except central lines could not be determined because of the low prevalence of the outcome. CONCLUSIONS:There appears to be a need to develop a risk stratification strategy to guide physicians to manage febrile patients with SCD based on factors including, but not limited to, history and clinical examination, vaccination status, use of prophylactic antibiotics, laboratory values, likely source of infection, and accessibility to health care.
PMID: 31851075
ISSN: 1535-1815
CID: 4428542

Predicting Urinary Tract Infections With Interval Likelihood Ratios

Liang, Tian; Schibeci Oraa, Silvia; Rebollo Rodríguez, Naomi; Bagade, Tanvi; Chao, Jennifer; Sinert, Richard
BACKGROUND:Protocols for diagnosing urinary tract infection (UTI) often use arbitrary cutoff values of urinalysis components to guide management. Interval likelihood ratios (ILRs) of urinalysis results may improve the test's precision in predicting UTIs. We calculated the ILR of urinalysis components to estimate the posttest probabilities of UTIs in young children. METHODS:Review of 2144 visits to the pediatric emergency department of an urban academic hospital from December 2011 to December 2019. Inclusion criteria were age <2 years and having a urinalysis and urine culture sent. ILR boundaries for hemoglobin, protein, and leukocyte esterase were "negative," "trace," "1+," "2+" and "3+." Nitrite was positive or negative. Red blood cells and white blood cells (WBCs) were 0 to 5, 5 to 10, 10 to 20, 20 to 50, 50 to 100, and 100 to 250. Bacteria counts ranged from negative to "loaded." ILRs for each component were calculated and posttest probabilities for UTI were estimated. RESULTS:(75.2%). The ILR for leukocyte esterase ranged from 0.20 (negative) to 37.68 (3+) and WBCs ranged from 0.24 (0-5 WBCs) to 47.50 (100-250 WBCs). The ILRs for nitrites were 0.76 (negative) and 25.35 (positive). The ILR for negative bacteria on urinalysis was 0.26 and 14.04 for many bacteria. CONCLUSIONS:The probability of UTI in young children significantly increases with 3+ leukocyte esterase, positive nitrite results, 20 to 50 or higher WBCs, and/or many or greater bacteria on urinalysis. The probability of UTI only marginally increases with trace or 1+ leukocyte esterase or 5 to 20 WBCs. Our findings can be used to more accurately predict the probability of true UTI in children.
PMID: 33277351
ISSN: 1098-4275
CID: 4702542

Utilization of Pediatric Emergency Care in New York City During the Coronavirus Disease 2019 Pandemic [Meeting Abstract]

Liang, Tian; Meltzer, J; Waseem, M; Tay, E; Chao, J; Mortel, D; Lee, H; Agoritsas, K; Chamdawala, H
ISSN: 1553-2712
CID: 5007462

Rochester Criteria and Yale Observation Scale Score in Febrile Neonates to Evaluate Invasive Bacterial Infection [Meeting Abstract]

Molyneaux, Neh; Liang, Tian; Sinert, Richard; Chao, Jennifer
ISSN: 1069-6563
CID: 5007052

Patient-provider communication and hormonal therapy side effects in breast cancer survivors

Lin, Jenny J; Chao, Jennifer; Bickell, Nina A; Wisnivesky, Juan P
Side effects from hormonal therapy (HT) for breast cancer treatment occur frequently and are associated with worse quality of life and HT non-adherence. Whether improved patient-physician communication is associated with patients' reporting of side effects is unknown. We undertook this study to assess factors associated with women's reports of HT side effects. Between December 2012 and April 2013, we conducted a cross-sectional survey of breast cancer patients undergoing HT in an urban medical center. Descriptive statistics, univariate analyses, and multivariate analyses were used to evaluate associations. Of the 100 participants, 67% reported having HT side effects. However, when prompted, an additional 9% reported experiencing specific HT-related symptoms. Despite very high communication scores, one-third of participants reported they had not discussed side effects with providers. Multivariate analysis showed that after controlling for age, education, race, and medication beliefs, women who had difficulty asking providers for more information were more likely to report side effects (odds ratio 8.27, 95% confidence interval 1.01-69.88). Although HT side effects often occur and are bothersome, patient-provider discussions about side effects remain suboptimal. Providers should actively ask patients about medication side effects so that they can be addressed to improve quality of life and potentially, medication adherence.
PMID: 27618729
ISSN: 1541-0331
CID: 3090432

Polypill: Can its Potential Enhancement of Efficacy Trigger New Interest? [Editorial]

Chao, Jennifer; Bansilal, Sameer
PMID: 27938845
ISSN: 2211-8179
CID: 4064332

Hepatitis B and Hepatocellular Carcinoma Screening Practices in Chinese and African Immigrant-Rich Neighborhoods in New York City

Fitzgerald, S; Chao, J; Feferman, Y; Perumalswami, P; Sarpel, U
BACKGROUND:Immigrants from China and Africa have high rates of hepatitis B virus infection (HBV) and hepatocellular carcinoma (HCC); however, primary care physician (PCP) adherence to screening guidelines in at-risk communities is not well understood. METHODS:The New York City (NYC) neighborhood tabulation areas with the 25 greatest Chinese and African immigrant populations were determined based on US census data. The American Medical Association database was used to identify PCPs practicing in these neighborhoods. A Web-based survey designed to assess HBV and HCC knowledge and screening practices was distributed via e-mail to PCPs in these target areas. RESULTS:A total of 2072 physicians were contacted, and 109 responded to the survey, for a response rate of 5.3 %. Among responding physicians, 73 % report routinely testing immigrant patients for HBV. However, if a patient tests positive for HBV, only 68 % of providers recommend screening for HCC. Over a quarter of PCPs (27 %), failed to correctly state that antiviral therapy can lower the risk of developing HCC, and only 56 % correctly replied that screening for liver cancer improves survival. Of responders, only 54 % answered correctly that a 25-year-old patient from Africa with HBV should be screened for HCC, whereas 53 % answered incorrectly that a 25-year-old patient from China with HBV should be screened, demonstrating a lack of awareness of the different age of onset of liver cancer in the two groups. The most commonly reported barrier to offering both HBV testing and HCC screening was a "lack of clear guidelines." Neither HBV nor HCC was among the top 3 health concerns of patients, as perceived by their physicians. There were no significant differences between provider responses in Chinese and African immigrant neighborhoods. CONCLUSIONS:Providers serving Chinese and African immigrants in NYC often fail to recommend appropriate HBV and HCC screening. This appears to be due to significant gaps in provider knowledge and a lack of awareness of established screening guidelines. This study suggests the need for better distribution of existing guidelines to physicians serving immigrant-rich communities in order to improve HBV and HCC screening in high-risk individuals.
PMID: 27797012
ISSN: 2196-8837
CID: 4064322

Premature ventricular complexes on screening electrocardiogram and risk of ischemic stroke

Agarwal, Sunil K; Chao, Jennifer; Peace, Frederick; Judd, Suzanne E; Kissela, Brett; Kleindorfer, Dawn; Howard, Virginia J; Howard, George; Soliman, Elsayed Z
BACKGROUND AND PURPOSE/OBJECTIVE:Premature ventricular complexes (PVCs) detected from long-term ECG recordings have been associated with an increased risk of ischemic stroke. Whether PVCs seen on routine ECG, commonly used in clinical practice, are associated with an increased risk of ischemic stroke remains unstudied. METHODS:This analysis included 24 460 participants (aged, 64.5+9.3 years; 55.1% women; 40.0% blacks) from the Reasons for Geographic and Racial Differences in Stroke (REGARDS) study who were free of stroke at the time of enrollment. PVCs were ascertained from baseline ECG (2003-2007), and incident stroke cases through 2011 were confirmed by an adjudication committee. RESULTS:A total of 1415 (5.8%) participants had at least 1 PVC at baseline, and 591 developed incident ischemic stroke during an average (SD) follow-up of 6.0 (2.0) years. In a cox proportional hazards model adjusted for age, sex, race, geographic region, education, previous heart disease, systolic blood pressure, blood pressure-lowering medications, current smoking, diabetes mellitus, left ventricular hypertrophy by ECG, and aspirin use and warfarin use, the presence of PVCs was associated with 38% increased risk of ischemic stroke (hazard ratio [95% confidence interval], 1.38 [1.05-1.81]). CONCLUSIONS:PVCs are common on routine screening ECGs and are associated with an increased risk of ischemic stroke.
PMID: 25873602
ISSN: 1524-4628
CID: 4064312