Respiratory syncytial virus (RSV) bronchiolitis is not only the leading cause of hospitalization in U.S. infants, but also a major risk factor for asthma development. While emerging evidence suggests ...clinical heterogeneity within RSV bronchiolitis, little is known about its biologically-distinct endotypes. Here, we integrated clinical, virus, airway microbiome (species-level), transcriptome, and metabolome data of 221 infants hospitalized with RSV bronchiolitis in a multicentre prospective cohort study. We identified four biologically- and clinically-meaningful endotypes: A) clinical
microbiome
inflammation
, B) clinical
microbiome
inflammation
, C) clinical
microbiome
inflammation
, and D) clinical
microbiome
inflammation
. Particularly, compared with endotype A infants, endotype B infants-who are characterized by a high proportion of IgE sensitization and rhinovirus coinfection, S. pneumoniae/M. catarrhalis codominance, and high IFN-α and -γ response-had a significantly higher risk for developing asthma (9% vs. 38%; OR, 6.00: 95%CI, 2.08-21.9; P = 0.002). Our findings provide an evidence base for the early identification of high-risk children during a critical period of airway development.
To investigate the temporal trend in the national incidence of bronchiolitis hospitalizations, their characteristics, inpatient resource use, and hospital cost from 2000 through 2016.
We performed a ...serial, cross-sectional analysis of nationally representative samples (the 2000, 2003, 2006, 2009, 2012, and 2016 Kids' Inpatient Databases) of children (age <2 years) hospitalized for bronchiolitis. We identified all children hospitalized with bronchiolitis by using
466.1 and
J21. Complex chronic conditions were defined by the pediatric complex chronic conditions classification by using inpatient data. The primary outcomes were the incidence of bronchiolitis hospitalizations, mechanical ventilation use, and hospital direct cost. We examined the trends accounting for sampling weights.
From 2000 to 2016, the incidence of bronchiolitis hospitalization decreased from 17.9 to 13.5 per 1000 person-years in US children (25% decrease;
< .001). In contrast, the proportion of bronchiolitis hospitalizations among overall hospitalizations increased from 16% to 18% (
< .001). There was an increase in the proportion of children with a complex chronic condition (6%-13%; 117% increase), hospitalization to children's hospital (15%-29%; 93% increase), and mechanical ventilation use (2%-5%; 184% increase; all
< .001). Likewise, the hospital cost increased from $449 million to $734 million (63% increase) nationally (with an increase in geometric mean of cost per hospitalization from $3267 to $4086; 25% increase;
< .001 adjusted for inflation) from 2003 to 2016.
From 2000 through 2016, the incidence of bronchiolitis hospitalizations among US children declined. In contrast, mechanical ventilation use and nationwide hospital direct cost substantially increased.
Development of emergency department (ED) triage systems that accurately differentiate and prioritize critically ill from stable patients remains challenging. We used machine learning models to ...predict clinical outcomes, and then compared their performance with that of a conventional approach-the Emergency Severity Index (ESI).
Using National Hospital and Ambulatory Medical Care Survey (NHAMCS) ED data, from 2007 through 2015, we identified all adult patients (aged ≥ 18 years). In the randomly sampled training set (70%), using routinely available triage data as predictors (e.g., demographics, triage vital signs, chief complaints, comorbidities), we developed four machine learning models: Lasso regression, random forest, gradient boosted decision tree, and deep neural network. As the reference model, we constructed a logistic regression model using the five-level ESI data. The clinical outcomes were critical care (admission to intensive care unit or in-hospital death) and hospitalization (direct hospital admission or transfer). In the test set (the remaining 30%), we measured the predictive performance, including area under the receiver-operating-characteristics curve (AUC) and net benefit (decision curves) for each model.
Of 135,470 eligible ED visits, 2.1% had critical care outcome and 16.2% had hospitalization outcome. In the critical care outcome prediction, all four machine learning models outperformed the reference model (e.g., AUC, 0.86 95%CI 0.85-0.87 in the deep neural network vs 0.74 95%CI 0.72-0.75 in the reference model), with less under-triaged patients in ESI triage levels 3 to 5 (urgent to non-urgent). Likewise, in the hospitalization outcome prediction, all machine learning models outperformed the reference model (e.g., AUC, 0.82 95%CI 0.82-0.83 in the deep neural network vs 0.69 95%CI 0.68-0.69 in the reference model) with less over-triages in ESI triage levels 1 to 3 (immediate to urgent). In the decision curve analysis, all machine learning models consistently achieved a greater net benefit-a larger number of appropriate triages considering a trade-off with over-triages-across the range of clinical thresholds.
Compared to the conventional approach, the machine learning models demonstrated a superior performance to predict critical care and hospitalization outcomes. The application of modern machine learning models may enhance clinicians' triage decision making, thereby achieving better clinical care and optimal resource utilization.
There have been few studies in non-western countries on the relationship between low levels of daily fine particulate matter (PM2.5) exposure and morbidity or mortality, and the impact of PM2.5 ...concentrations below 15 μg/m3, which is the latest World Health Organization Air Quality Guideline (WHO AQG) value for the 24-h mean, is not yet clear. We assessed the associations between low-level PM2.5 exposure and cardiorespiratory admissions in Japan. We collected the daily hospital admission count data, air pollutant data, and meteorological condition data recorded from April 2016 to March 2019 in 139 Japanese cities. City-specific estimates were obtained from conditional logistic regression models in a time-stratified case-crossover design and pooled by random-effect models. We estimated that every 10-μg/m3 increase in the concurrent-day PM2.5 concentration was related to a 0.52% increase in cardiovascular admissions (95% CI: 0.13–0.92%) and a 1.74% increase in respiratory admissions (95% CI: 1.41–2.07%). These values were nearly the same when the datasets were filtered to contain only daily PM2.5 concentrations <15 μg/m3. The exposure–response curves showed approximately sublinear-to-linear curves with no indication of thresholds. These associations with cardiovascular diseases weakened after adjusting for nitrogen dioxide or sulfur dioxide, but associations with respiratory diseases were almost unchanged when additionally adjusted for other pollutants. This study demonstrated that associations between daily PM2.5 and daily cardiorespiratory hospitalizations might persist at low concentrations, including those below the latest WHO AQG value. Our findings suggest that the updated guideline value may still be insufficient from the perspective of public health.
•PM2.5 exposure was associated with increased cardiorespiratory admissions.•These associations generally persisted at low daily mean concentrations <15 μg/m3.•The respiratory associations were unchanged after adjusting for other pollutants.
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GEOZS, IJS, IMTLJ, KILJ, KISLJ, NLZOH, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UILJ, UL, UM, UPCLJ, UPUK, ZAGLJ, ZRSKP
Clinical and epidemiologic studies have shown that obesity is associated with asthma and that these associations differ by asthma subtype. Little is known about the shared genetic components between ...obesity and asthma.
We sought to identify shared genetic associations between obesity-related traits and asthma subtypes in adults.
A cross-trait genome-wide association study (GWAS) was performed using 457,822 subjects of European ancestry from the UK Biobank. Experimental evidence to support the role of genes significantly associated with both obesity-related traits and asthma through a GWAS was sought by using results from obese versus lean mouse RNA sequencing and RT-PCR experiments.
We found a substantial positive genetic correlation between body mass index and later-onset asthma defined by asthma age of onset at 16 years or greater (Rg = 0.25, P = 9.56 × 10−22). Mendelian randomization analysis provided strong evidence in support of body mass index causally increasing asthma risk. Cross-trait meta-analysis identified 34 shared loci among 3 obesity-related traits and 2 asthma subtypes. GWAS functional analyses identified potential causal relationships between the shared loci and Genotype-Tissue Expression (GTEx) quantitative trait loci and shared immune- and cell differentiation–related pathways between obesity and asthma. Finally, RNA sequencing data from lungs of obese versus control mice found that 2 genes (acyl-coenzyme A oxidase-like ACOXL and myosin light chain 6 MYL6) from the cross-trait meta-analysis were differentially expressed, and these findings were validated by using RT-PCR in an independent set of mice.
Our work identified shared genetic components between obesity-related traits and specific asthma subtypes, reinforcing the hypothesis that obesity causally increases the risk of asthma and identifying molecular pathways that might underlie both obesity and asthma.
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GEOZS, IJS, IMTLJ, KILJ, KISLJ, NLZOH, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UILJ, UL, UM, UPCLJ, UPUK, ZAGLJ, ZRSKP
Background
As the U.S. homeless population grows, so has the challenge of providing effective care to homeless individuals. Understanding hospitals that achieve better outcomes after hospital ...discharge for homeless patients has important implications for making our health system more sustainable and equitable.
Objective
To determine whether homeless patients experience higher rates of readmissions and emergency department (ED) visits after hospital discharge than non-homeless patients, and whether the homeless patients exhibit lower rates of readmissions and ED visits after hospital discharge when they were admitted to hospitals experienced with the treatment of the homeless patients (“homeless-serving” hospitals—defined as hospitals in the top decile of the proportion of homeless patients).
Design
A population-based longitudinal study, using the data including all hospital admissions and ED visits in FL, MA, MD, and NY in 2014.
Participants
Participants were 3,527,383 patients (median age IQR: 63 49–77 years; 1,876,466 53% women; 134,755 4% homeless patients) discharged from 474 hospitals.
Main Measures
Risk-adjusted rates of 30-day all-cause readmissions and ED visits after hospital discharge.
Key Results
After adjusting for potential confounders, homeless patients had higher rates of readmissions (adjusted rate, 27.3% vs. 17.5%; adjusted odds ratio aOR, 1.93; 95% CI, 1.69–2.21;
p
< 0.001) and ED visits after hospital discharge (37.1% vs. 23.6%; aOR, 1.98; 95% CI, 1.74–2.25;
p
< 0.001) compared with non-homeless patients. Homeless patients treated at homeless-serving hospitals exhibited lower rates of readmissions (23.9% vs. 33.4%;
p
< 0.001) and ED visits (31.4% vs. 45.4%;
p
< 0.001) after hospital discharge than homeless patients treated at non-homeless-serving hospitals.
Conclusions
Homeless patients were more likely to be readmitted or return to ED within 30 days after hospital discharge, especially when they were treated at hospitals that treat a small proportion of homeless patients. These findings suggest that homeless patients may receive better discharge planning and care coordination when treated at hospitals experienced with caring for homeless people.
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EMUNI, FIS, FZAB, GEOZS, GIS, IJS, IMTLJ, KILJ, KISLJ, MFDPS, NLZOH, NUK, OBVAL, OILJ, PNG, SAZU, SBCE, SBJE, SBMB, SBNM, UKNU, UL, UM, UPUK, VKSCE, ZAGLJ
Study objective Although repeated intubation attempts are believed to contribute to patient morbidity, only limited data characterize the association between the number of emergency department (ED) ...laryngoscopic attempts and adverse events. We seek to determine whether multiple ED intubation attempts are associated with an increased risk of adverse events. Methods We conducted an analysis of a multicenter prospective registry of 11 Japanese EDs between April 2010 and September 2011. All patients undergoing emergency intubation with direct laryngoscopy as the initial device were included. The primary exposure was multiple intubation attempts, defined as intubation efforts requiring greater than or equal to 3 laryngoscopies. The primary outcome measure was the occurrence of intubation-related adverse events in the ED, including cardiac arrest, dysrhythmia, hypotension, hypoxemia, unrecognized esophageal intubation, regurgitation, airway trauma, dental or lip trauma, and mainstem bronchus intubation. Results Of 2,616 patients, 280 (11%) required greater than or equal to 3 intubation attempts. Compared with patients requiring 2 or fewer intubation attempts, patients undergoing multiple attempts exhibited a higher adverse event rate (35% versus 9%). After adjusting for age, sex, principal indication, method, medication, and operator characteristics, intubations requiring multiple attempts were associated with an increased odds of adverse events (odds ratio 4.5; 95% confidence interval 3.4 to 6.1). Conclusion In this large Japanese multicenter study of ED patients undergoing intubation, we found that multiple intubation attempts were independently associated with increased adverse events.
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GEOZS, IJS, IMTLJ, KILJ, KISLJ, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UL, UM, UPCLJ, UPUK
The effectiveness of the long-term care service in Japan has been unclear, and most of the relevant studies of this service have been limited to a single region and relatively small samples, ...necessitating large-scale studies. We examined the associations between long-term care service use and the service/care-need level progression at the national scale in Japan.
We conducted a nationwide retrospective cohort study using data from the Japanese Long-Term Care Insurance Claims database. Individuals aged ≥ 65 years and newly certified as being at the support-need level 1 or 2 or the care-need level 1 between April 2012 and March 2013 were included. We first conducted 1:1 propensity score matching and then examined the associations between service use and the progression in support-need or care-need levels by using Kaplan-Meier survival curves and log-rank tests.
The final sample consisted of 332,766 individuals. We observed that service use was associated with a faster decline in the support/care-need level, although the differences in the subjects' survival rate diminished; the log-rank test showed significance (p < 0.001). When stratified for urban-rural classifications or regions of Japan, the results were similar to the primary analysis in all of the stratified groups, and no clear regional variations were observed.
We did not observe a clear beneficial effect of receiving long-term care in Japan. Our results suggest that Japan's current long-term care service may not be effective for the recipients of these services. Considering that the system is becoming a financial burden, a re-examination of the service to provide more cost-effective care may be advisable.
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CEKLJ, DOBA, IZUM, KILJ, NUK, PILJ, PNG, SAZU, SIK, UILJ, UKNU, UL, UM, UPUK
The microstructure and mechanical properties of a low-carbon steel produced via the quenching & partitioning (Q&P) heat treatment was investigated, with particular focus on the hole expansion ratio, ...which is an index of the stretch-flange-formability. 0.19mass%C-1.5mass%Si-2.9mass%Mn steel was annealed at 850 ˚C, then cooled to 150~400 ˚C (QT: quench temperature), followed by holding at 400˚C for 1100 s. Yield strength and hole expansion ratio drastically increased when the QT was below the Ms (martensite start) temperature. The steel with QT of 300 ˚C exhibited not only a higher elongation, which has been well documented, but also a higher hole expansion ratio, when compared to the conventional TRIP steel with QT of 400 ˚C having equal tensile strength around 1200 MPa. The micro-void formation during deformation was suppressed in the steel with QT of 300 ˚C due to the smaller volume fraction of large blocky martensite compared to the TRIP steel. These excellent mechanical properties are attributed to its unique microstructure consisting of a certain amount of tempered martensite, lath-shaped retained austenite and bainitic ferrite, which was generated via the Q&P heat treatment.
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