Kyle A. Nelson

Incremental prognostic value of coronary artery calcium score versus CT angiography among symptomatic patients without known coronary artery disease

OBJECTIVE To evaluate the prognostic value and test characteristics of coronary artery calcium (CAC) score for the identification of obstructive coronary artery disease (CAD) in comparison with coronary computed tomography angiography (CCTA) among symptomatic patients. METHODS Retrospective cohort study at two large hospitals, including all symptomatic patients without prior CAD who underwent both CCTA and CAC. Accuracy of CAC for the identification of ≥ 50% and ≥ 70% stenosis by CCTA was evaluated. Prognostic value of CAC and CCTA were compared for prediction of major adverse cardiovascular events (MACE, defined as non-fatal myocardial infarction, cardiovascular death, late coronary revascularization (>90 days), and unstable angina requiring hospitalization). RESULTS Among 1145 included patients, the mean age was 55 ± 12 years and median follow up 2.4 (IQR: 1.5-3.5) years. Overall, 406 (35%) CCTA were normal, 454 (40%) had <50% stenosis, and 285 (25%) had ≥ 50% stenosis. The prevalence of ≥ 70% stenosis was 16%. Among 483 (42%) patients with CAC zero, 395 (82%) had normal CCTA, 81 (17%) <50% stenosis, and 7 (1.5%) ≥ 50% stenosis. 2 (0.4%) patients had ≥ 70% stenosis. For diagnosis of ≥ 50% stenosis, CAC had a sensitivity of 98% and specificity of 55%. The negative predictive value (NPV) for CAC was 99% for ≥ 50% stenosis and 99.6% for ≥ 70% stenosis by CCTA. There were no adverse events among the 7 patients with zero calcium and ≥ 50% CAD. For prediction of MACE, the c-statistic for clinical risk factors of 0.62 increased to 0.73 (p < 0.001) with CAC versus 0.77 (p = 0.02) with CCTA. CONCLUSION Among symptomatic patients with CAC zero, a 1-2% prevalence of potentially obstructive CAD occurs, although this finding was not associated with future coronary revascularization or adverse prognosis within 2 years.

A Randomized Controlled Trial of Parental Asthma Coaching to Improve Outcomes Among Urban Minority Children

OBJECTIVES To investigate whether asthma coaching decreases emergency department (ED) visits and hospitalizations and increases outpatient asthma monitoring visits. DESIGN Randomized controlled trial. SETTING Urban tertiary care childrens hospital. PARTICIPANTS Primary caregivers (hereafter referred to as parents) of children aged 2 to 10 years with asthma who have Medicaid insurance coverage and are urban residents who were attending the ED for acute asthma care. INTERVENTION Eighteen months of participating in usual care (control group) vs receiving coaching focused on asthma home management, completion of periodic outpatient asthma monitoring visits, and development of a collaborative relationship with a primary care provider (intervention group). MAIN OUTCOME MEASURES The primary outcome was ED visits. Secondary outcomes were hospitalizations and asthma monitoring visits (nonacute visits focused on asthma care). Outcomes were measured during the year before and 2 years after enrollment. RESULTS We included 120 intervention parents and 121 control parents. More children of coached parents had at least 1 asthma monitoring visit after enrollment (relative risk [RR], 1.21; 95% confidence interval [CI], 1.04-1.41), but proportions with at least 4 asthma monitoring visits during 2 years were low (20.0% in the intervention group vs 9.9% in the control group). Similar proportions of children in both study groups had at least 1 ED visit (59.2% in the intervention group vs 62.8% in the control group; RR, 0.94; 95% CI, 0.77-1.15) and at least 1 hospitalization (24.2% in the intervention group vs 26.4% in the control group; 0.91; 0.59-1.41) after enrollment. An ED visit after enrollment was more likely if an ED visit had occurred before enrollment (RR, 1.46; 95% CI, 1.16-1.86; adjusted for study group), but risk was similar in both study groups when adjusted for previous ED visits (1.02; 0.82-1.27). CONCLUSION This parental asthma coaching intervention increased outpatient asthma monitoring visits (although infrequent) but did not decrease ED visits. TRIAL REGISTRATION clinicaltrials.gov Identifier: NCT00149500.

The Residential Segregation of Mixed-Nativity Married Couples

This article examines the ways in which mixed-nativity marriage is related to spatial assimilation in metropolitan areas of the United States. Specifically, we examine the residential patterns of households with a mixed-nativity—and, in some cases, interracial—marriage to determine whether they are less segregated from the native-born than entirely foreign-born households. Using restricted-use data from the 2000 census, we find that compared with couples in which both spouses are foreign-born, mixed-nativity couples tend to be less segregated from various native-born racial and ethnic groups. Further, among both foreign-born Asians and Hispanics, those with a native-born non-Hispanic white spouse are considerably less segregated from native-born white households than from other foreign-born Asian and Hispanic households. We also find that even though nativity status matters for black couples in a manner consistent with assimilation theory, foreign-born and mixed-nativity black households still each display very high levels of segregation from all other native-born racial/ethnic groups, reaffirming the power of race in determining residential patterns. Overall, our findings provide moderate support for spatial assimilation theory and suggest that cross-nativity marriages often facilitate the residential integration of the foreign-born.

Pilot study of oral montelukast added to standard therapy for acute asthma exacerbations in children aged 6 to 14 years.

Objective: We hypothesized that children with moderate acute asthma exacerbations receiving oral montelukast with standard therapy will have at least 12% greater forced expiratory volume in 1 second (FEV1) improvement in 3 hours than those receiving standard therapy alone. Methods: In this randomized, double-blind, placebo-controlled study, we enrolled emergency patients aged 6 to 14 years with moderate acute asthma exacerbations (peak expiratory flow rate, 40%-70% predicted). Subjects received montelukast 5 mg or placebo orally then standard therapy. We measured FEV1 before study medication administration and hourly for 3 hours. The primary outcome was FEV1% predicted change at 3 hours. Results: At the time of the planned interim analysis, we had enrolled 27 subjects; 23 (11 montelukast, 12 placebo) had a complete FEV1 data. Both groups had similar mean FEV1 increases at 3 hours (mean [SD]: montelukast = 16.8% [11.4%], placebo = 19.9% [12.1%]; 95% confidence interval for difference = −12.22% to 5.95%). Based on further analysis, we determined that enrollment of the planned sample was unlikely to significantly change the results. If our study hypothesis were true, the montelukast group mean FEV1 increase should be 32% or greater. The probabilities were low that the montelukast sample could be drawn from a normally distributed population with a mean of 32% and that subsequently enrolled montelukast subjects would have sufficient FEV1 improvements to attain a mean of greater than 32%. Conclusion: Based on these results, for children aged 6 to 14 years with moderate acute asthma exacerbations, oral montelukast (5 mg) added to standard therapy as in this design is unlikely to result in additional FEV1 improvements in 3 hours.

Risk Factors for Extremely Long Length-of-Stay Among Pediatric Emergency Patients

Objective: Over time, we observed more visits in our pediatric emergency department with length-of-stay (LOS) of more than 10 hours, whereas our mean LOS was approximately 3 hours. We sought to characterize factors associated with this extremely long LOS. Methods: Eighty-one visits with LOS more than 10 hours were identified from January 1, 2001, to June 30, 2003. In this retrospective study, we compared these cases with 405 randomly selected age-matched controls with LOS less than 10 hours (5 controls per case). Results: The groups were similar for sex, visit month, arrival mode, and level of training of the supervising physician. Cases more frequently arrived during night shifts (30% vs 13%) and had laboratory tests (93% vs 32%), radiological studies (83% vs 34%), procedures (28% vs 15%), sedations (24% vs 4%), subspecialty consultations (84% vs 20%), chief complaints of abdominal pain (42% vs 6%) and diagnoses of appendicitis (10% vs 1%), and had a greater hospitalization rate (67 vs 19%). Although more cases involved white patients (57% vs 31%), race was not associated with LOS more than 10 hours in adjusted analysis. In multivariable analysis, longer waiting time (odds ratio [OR], 1.013; 95% confidence interval [CI], 1.007-1.019), night shift arrival (OR, 5.0; 95% CI, 1.9-12.8), higher triage acuity (lowest acuity: OR, 0.003; 95% CI, 0.0-0.286), radiology study other than radiographs (OR, 18.0; 95% CI, 7.5-43.1), and subspecialty consultation (OR, 7.6; 95% CI, 3.2-18.3) were associated with LOS more than 10 hours. Conclusions: In our pediatric emergency department, risk factors for LOS more than 10 hours included longer waiting time, night shift arrivals, high triage acuity, radiology studies, and subspecialty consultations. These factors may also be important considerations for quality improvement initiatives at other institutions.

Neisseria sicca endocarditis requiring mitral valve replacement in a previously healthy adolescent.

Infective endocarditis due to Neisseria sicca, a normal inhabitant of the upper respiratory tract, is rarely reported but associated with embolic phenomena and large vegetations often requiring surgical intervention. We report a previously healthy 12-year-old girl who presented with prolonged fever and altered mental status. The patient developed rapidly progressive respiratory insufficiency and cardiovascular instability, and echocardiography demonstrated a large vegetation on the mitral valve. She developed worsening mitral regurgitation with resultant pulmonary hemorrhage and underwent mitral valve replacement. Her blood culture was positive for N. sicca. This infection should be considered in patients with prolonged high fever and multiorgan dysfunction. Despite a typically severe course, reported mortality is low.

Detection and home management of worsening asthma symptoms.

BACKGROUND Asthma guidelines recommend early home treatment of exacerbations. However, home treatment is often suboptimal and delayed. OBJECTIVES To describe antecedent symptoms and signs of asthma exacerbations noticed by parents and to learn when and how parents intensify asthma treatment. METHODS Parents of children 2 to 12 years old with asthma exacerbations that required urgent care in the past 12 months completed telephone questionnaires. Where multiple responses were possible, percentages may sum to more than 100%. RESULTS One hundred one parents were enrolled and interviewed; 94% were the childrens mothers. Seventy percent of the children were black, and 64% had Medicaid insurance. Parents reported multiple antecedent symptoms and signs (median number per child, 3; range, 1-6), including respiratory symptoms (79%), allergy or cold symptoms (43%), behavioral changes (24%), and other nonspecific symptoms (29%). Twenty-three parents reported late respiratory symptoms, such as gasping for breath and using accessory muscles to breath, as the earliest antecedent signs. Treatment was most often intensified when the parent noticed cough (55%), shortness of breath (54%), and wheeze (25%) and included adding albuterol (92%), an oral corticosteroid (17%), an inhaled corticosteroid (8%), or other nonasthma medications (16%). CONCLUSIONS Although parents described antecedent symptoms and signs of impending asthma exacerbations that they consistently noticed in their children, many waited for lower respiratory signs to be present before intensifying treatment. Oral corticosteroids were used infrequently. Interventions to improve the ability of parents and children to accurately recognize worsening symptoms and initiate timely, effective treatment are needed.

Impact of Chest Radiography on Antibiotic Treatment for Children With Suspected Pneumonia.

Objective National guidelines discourage routine chest radiographs (CXRs) to confirm suspected pneumonia in children managed as outpatients. However, limiting CXRs may lead to antibiotic overuse. We examined the impact of CXRs and clinical suspicion on antibiotic treatment for children with suspected pneumonia. Methods Children aged 3 months to 18 years undergoing CXR for suspected pneumonia in a pediatric emergency department were prospectively enrolled. Before CXR, physicians indicated their initial plan for antibiotics (yes or no) and clinical suspicion for radiographic pneumonia (<5%, 5–10%, 11–20%, 21–50%, 51–75%, >75%). Subjects had radiographic pneumonia if their CXRs demonstrated definite or possible findings of pneumonia. We compared antibiotic treatment according to pre-CXR antibiotic plan and suspicion for pneumonia and CXR results. Results Among the 107 children with a plan for antibiotics before CXR, 72% ultimately received antibiotics compared with 19% of the 1503 children without a pre-CXR plan for antibiotics (P < 0.001). Among those patients with a pre-CXR plan for antibiotics, 96% of children with radiographic pneumonia were ultimately treated compared with 54% without radiographic pneumonia (P < 0.001). If antibiotics were not initially planned, 37% with radiographic pneumonia were treated compared with 8% without radiographic pneumonia (P < 0.001). The use of CXR was more likely to influence antibiotic prescribing patterns when the clinical suspicion of pneumonia was low (<20%). Conclusions Among children with high suspicion for pneumonia, CXRs infrequently altered the initial plan for antibiotics. However, when clinical suspicion for pneumonia was low, the use of CXR may reduce unnecessary antibiotic use.

Does residential segregation help or hurt? Exploring differences in the relationship between segregation and health among U.S. Hispanics by nativity and ethnic subgroup

Abstract In order to unpack whether and how self-rated health of Hispanics is linked to residential segregation from non-Hispanic whites, this study employs multi-level analysis combining data from the 1997–2002 National Survey of Americas Families (n = 16,753 Hispanic respondents across 82 metropolitan areas) with metropolitan area segregation scores derived from restricted-use Census 2000 data. Separate analyses by nativity (U.S.-born vs. foreign-born Hispanics) and ethnic subgroup (comparing Mexicans, Puerto Ricans, and Cubans) are also conducted. Net of individual-level controls, findings reveal a small significant negative effect of segregation on health for all Hispanics and for Mexicans in the sample. Nativity does not have a significant interaction effect. Evidence of a positive segregation/health link is found for Cubans, challenging the assumption that segregation is always bad for minority health. This research highlights the value of multi-level analysis in examining segregation as a social determinant of health, and reveals key Hispanic subgroup differences.

Emergency Department Management of Febrile Respiratory Illness in Children.

Background There are limited data regarding testing and treatment patterns for children presenting to the emergency department (ED) with a febrile respiratory illness. Objectives The aims of the study were to evaluate the rates of diagnostic testing, antibiotic use, and pneumonia diagnosis among children presenting to an ED with a febrile respiratory illness and to evaluate whether differences exist on the basis of care at a pediatric versus a general ED. Methods Cross-sectional study of children presenting to an ED with a febrile respiratory illness from 2001 to 2010 used the National Hospital Ambulatory Medical Care Survey. Using extrapolated estimates from the weighted population sample, rates of laboratory and radiographic testing, antibiotic use, and pneumonia diagnosis were ascertained. Comparisons were made between children treated at a general versus pediatric ED. A subpopulation of children undergoing chest radiograph was identified to target those with concern for radiographic pneumonia. Results Fifteen percent of the 12 million visits for febrile respiratory illness occurred in a pediatric ED. Thirteen percent (95% confidence interval [CI], 11–15) of patients had a complete blood count, 4% (95% CI, 3–5) had a blood culture, and 33% (95% CI, 30–35) had a chest radiograph obtained; no differences were observed on the basis of ED type. Despite similar rates of pneumonia diagnosis, antibiotics were prescribed less often for children cared for in a pediatric (35% [95% CI, 30–41]) versus general ED (50% [95% CI, 47–53]). Similar findings were observed among the subgroup of children with febrile respiratory illness undergoing chest radiograph. Conclusions High rates of diagnostic testing were observed among children with febrile respiratory illnesses, despite low rates of pneumonia diagnosis. Antibiotic use was higher among children cared for at a general ED compared with pediatric ED.