Can a Home-based Cardiac Physical Activity Program Improve the Physical Function Quality of Life in Children with Fontan Circulation?

Objective Patients after Fontan operation for complex congenital heart disease (CHD) have decreased exercise capacity and report reduced health-related quality of life (HRQOL). Studies suggest hospital-based cardiac physical activity programs can improve HRQOL and exercise capacity in patients with CHD; however, these programs have variable adherence rates. The impact of a home-based cardiac physical activity program in Fontan survivors is unclear. This pilot study evaluated the safety, feasibility, and benefits of an innovative home-based physical activity program on HRQOL in Fontan patients. Methods A total of 14 children, 8–12 years, with Fontan circulation enrolled in a 12-week moderate/high intensity home-based cardiac physical activity program, which included a home exercise routine and 3 formalized in-person exercise sessions at 0, 6, and 12 weeks. Subjects and parents completed validated questionnaires to assess HRQOL. The Shuttle Test Run was used to measure exercise capacity. A Fitbit Flex Activity Monitor was used to assess adherence to the home activity program. Results Of the 14 patients, 57% were male and 36% had a dominant left ventricle. Overall, 93% completed the program. There were no adverse events. Parents reported significant improvement in their child\u27s overall HRQOL (P \u3c .01), physical function (P \u3c .01), school function (P = .01), and psychosocial function (P  \u3c .01). Patients reported no improvement in HRQOL. Exercise capacity, measured by total shuttles and exercise time in the Shuttle Test Run and calculated VO2max, improved progressively from baseline to the 6 and 12 week follow up sessions. Monthly Fitbit data suggested adherence to the program. Conclusion This 12-week home-based cardiac physical activity program is safe and feasible in preteen Fontan patients. Parent proxy-reported HRQOL and objective measures of exercise capacity significantly improved. A 6-month follow up session is scheduled to assess sustainability. A larger study is needed to determine the applicability and reproducibility of these findings in other age groups and forms of complex CHD

Vitamin D Deficiency and Long-Term Cognitive Impairment Among Older Adult Emergency Department Patients

Introduction: Approximately 16% of acutely ill older adults develop new, long-term cognitive impairment (LTCI), many of whom initially seek care in the emergency department (ED). Currently, no effective interventions exist to prevent LTCI after an acute illness. Identifying early and modifiable risk factors for LTCI is the first step toward effective therapy. We hypothesized that Vitamin D deficiency at ED presentation was associated with LTCI in older adults.Methods: This was an observational analysis of a prospective cohort study that enrolled ED patients ≥ 65 years old who were admitted to the hospital for an acute illness. All patients were enrolled within four hours of ED presentation. Serum Vitamin D was measured at enrollment and Vitamin D deficiency was defined as serum concentrations <20 mg/dL. We measured pre-illness and six-month cognition using the short form Informant Questionnaire on Cognitive Decline in the Elderly (IQCODE), which ranges from 1 to 5 (severe cognitive impairment). Multiple linear regression was performed to determine whether Vitamin D deficiency was associated with poorer six-month cognition adjusted for pre-illness IQCODE and other confounders. We incorporated a two-factor interaction into the regression model to determine whether the relationship between Vitamin D deficiency and six-month cognition was modified by pre-illness cognition.Results: We included a total of 134 older ED patients; the median (interquartile range [IQR]) age was 74 (69, 81) years old, 61 (46%) were female, and 14 (10%) were nonwhite race. The median (IQR) vitamin D level at enrollment was 25 (18, 33) milligrams per deciliter and 41 (31%) of enrolled patients met criteria for vitamin D deficiency. Seventy-seven patients survived and had a six-month IQCODE. In patients with intact pre-illness cognition (IQCODE of 3.13), Vitamin D deficiency was significantly associated with worsening six-month cognition (β-coefficient: 0.43, 95% CI, 0.07 to 0.78, p = 0.02) after adjusting for pre-illness IQCODE and other confounders. Among patients with pre-illness dementia (IQCODE of 4.31), no association with Vitamin D deficiency was observed (β-coefficient: -0.1;, 95% CI, [-0.50-0.27], p = 0.56).Conclusion: Vitamin D deficiency was associated with poorer six-month cognition in acutely ill older adult ED patients who were cognitively intact at baseline. Future studies should determine whether early Vitamin D repletion in the ED improves cognitive outcomes in acutely ill older patients.

Low-Prandtl-number B\'enard-Marangoni convection in a vertical magnetic field

The effect of a homogeneous magnetic field on surface-tension-driven B\'{e}nard convection is studied by means of direct numerical simulations. The flow is computed in a rectangular domain with periodic horizontal boundary conditions and the free-slip condition on the bottom wall using a pseudospectral Fourier-Chebyshev discretization. Deformations of the free surface are neglected. Two- and three-dimensional flows are computed for either vanishing or small Prandtl number, which are typical of liquid metals. The main focus of the paper is on a qualitative comparison of the flow states with the non-magnetic case, and on the effects associated with the possible near-cancellation of the nonlinear and pressure terms in the momentum equations for two-dimensional rolls. In the three-dimensional case, the transition from a stationary hexagonal pattern at the onset of convection to three-dimensional time-dependent convection is explored by a series of simulations at zero Prandtl number.Comment: 26 pages, 9 figure

The cost of treating diabetic ketoacidosis in the UK: a national survey of hospital resource use

Aims: Diabetic ketoacidosis (DKA) is a commonly encountered metabolic emergency. In 2014 a national survey was conducted looking at the management of DKA in adult patients across the UK. The survey reported the clinical management of individual patients as well as institutional factors that teams felt were important in helping to deliver that care. However, costs of treating DKA were not reported. Methods: We used a ‘bottom up’ approach to cost analysis to determine the total expense associated with treating DKA in a mixed population sample. The data were derived from the source data from the national UK survey of 283 individual patients collected via questionnaires sent to hospitals across the country. Results: Because the initial survey collection tool was not designed with a health economic model in mind, several assumptions were made when analysing the data. The mean and median time in hospital was 5.6 and 2.7 days, respectively. Based on the individual patient data and using the Joint British Diabetes Societies Inpatient Care Group guidelines, the cost analysis shows that for this cohort, the average cost for an episode of DKA was £2064 per patient (95% CI: £1800, 2563). Conclusion: Despite relatively short stays in hospital, costs for managing episodes of DKA in adults were relatively high. Assumptions made in calculations did not take into account prolonged hospital stay due to co-morbidities nor costs incurred as a loss of productivity. Therefore the actual costs to the healthcare system and society in general are likely to be substantially higher

When Coverage Expands: Children's Health Insurance Program as a Natural Experiment in Use of Health Care Services

Background Expanding insurance coverage is designed to improve access to primary care and reduce use of emergency department ( ED ) services. Whether expanding coverage achieves this is of paramount importance as the United States prepares for the Affordable Care Act. Objectives Emergency and outpatient department use was examined after the State Children's Health Insurance Program ( CHIP ) coverage expansion, focusing on adolescents (a major target group for CHIP ) versus young adults (not targeted). The hypothesis was that coverage would increase use of outpatient services, and ED use would decrease. Methods Using the National Ambulatory Medical Care Survey ( NAMCS ) and the National Hospital Ambulatory Medical Care Survey ( NHAMCS ), the years 1992–1996 were analyzed as baseline and then compared to use patterns in 1999–2009, after the CHIP launch. Primary outcomes were population‐adjusted annual visits to ED versus nonemergency outpatient settings. Interrupted time series were performed on use rates to ED and outpatient departments between adolescents (11 to 18 years old) and young adults (19 to 29 years old) in the pre‐ CHIP and CHIP periods. Outpatient‐to‐ ED ratios were calculated and compared across time periods. A stratified analysis by payer and sex was also performed. Results The mean number of outpatient adolescent visits increased by 299 visits per 1,000 persons (95% confidence interval [ CI ] = 140 to 457), while there was no statistically significant increase in young adult outpatient visits across time periods. There was no statistically significant change in the mean number of adolescent ED visits across time periods, while young adult ED use increased by 48 visits per 1,000 persons (95% CI  = 24 to 73). The adolescent outpatient‐to‐ ED ratio increased by 1.0 (95% CI  = 0.49 to 1.6), while the young adults ratio decreased by 0.53 across time periods (95% CI  = –0.90 to –0.16). Conclusions Since CHIP , adolescent non‐ ED outpatient visits have increased, while ED visits have remained unchanged. In comparison to young adults, expanding insurance coverage to adolescents improved use of health care services and suggests a shift to non‐ ED settings. Expanding insurance through the Affordable Care Act of 2010 will likely increase use of outpatient services, but may not decrease ED volumes. Resumen Cuando la Cobertura se Amplia: Programa de Seguro Sanitario de Niños como un Experimento Natural en el Uso de los Servicios Sanitarios Introducción La ampliación de la cobertura del seguro se diseñó para mejorar el acceso a la atención primaria y reducir el uso de los servicios de urgencias ( SU ). El que esta ampliación de la cobertura lo consiga es de una importancia capital ya que Estados Unidos se prepara para la Ley del Cuidado de Salud Asequible (Affordable Care Act). Objetivos Se examinó el uso del servicio ambulatorio y de urgencias tras la ampliación de la cobertura del Programa de Seguro Sanitario de los Niños (Children's Health Insurance Program, CHIP ), por parte de los adolescentes (un gran grupo contemplado por el CHIP ) frente a los adultos jóvenes (no contemplado). La hipótesis fue que la cobertura incrementaría el uso de los servicios ambulatorios y disminuiría el de los SU . Metodología Utilizando la National Ambulatory Medical Care Survey y la National Hospital Ambulatory Medical Care Survey, se analizaron los años 1992–1996 como basal y después se compararon con los patrones de uso en 1999–2009, tras la introducción del CHIP . Los resultados principales fueron las visitas anuales a los SU frente a los servicios ambulatorios no urgentes ajustadas por la población. Se realizaron series temporales interrumpidas en las tasas de uso de los SU y los servicios ambulatorios entre adolescentes (11 a 18 años) y adultos jóvenes (19 a 29 años) en los periodos pre‐ CHI y CHIP . Se calcularon los porcentajes ambulatorio‐ SU y se compararon a través de los periodos de tiempo. Se realizó también un análisis estratificado por sexo y pagador. Resultados El número medio de visitas ambulatorias de adolescentes se incrementó 299 visitas por 1.000 personas ( IC 95% = 140 a 457), mientras que no hubo un incremento significativo en las visitas ambulatorias de adultos jóvenes a lo largo de los periodos de tiempo. No hubo cambio estadísticamente significativo en la media de número de visitas al SU de adolescentes a lo largo de los periodos de tiempo, mientras que se incrementó el uso de los SU de los adultos jóvenes, 48 visitas por 1.000 personas ( IC 95% = 24 a 73). La proporción ambulatorio‐ SU del adolescente se incrementó un 1,0 ( IC 95% = 0,49 a 1,6), mientras que la proporción de los adultos jóvenes descendió un 0,53 a lo largo de los periodos de tiempo ( IC 95% = –0,90 a –0,16). Conclusiones Desde el CHIP , las visitas ambulatorias no urgentes de los adolescentes se han incrementado, mientras que las visitas a los SU permanecen sin cambios. En comparación con los adultos jóvenes, la ampliación de la cobertura del seguro a los adolescentes mejoró el uso de los servicios sanitarios y sugiere un cambio hacia los servicios no relacionados con el SU . La ampliación del seguro a través de la Ley de Cuidado de Salud Asequible de 2010 incrementará probablemente el uso de los servicios ambulatorios, pero puede no disminuir los volúmenes del SU .Peer Reviewedhttp://deepblue.lib.umich.edu/bitstream/2027.42/100287/1/acem12236.pd

The validity of using ICD-9 codes and pharmacy records to identify patients with chronic obstructive pulmonary disease

Background: Administrative data is often used to identify patients with chronic obstructive pulmonary disease (COPD), yet the validity of this approach is unclear. We sought to develop a predictive model utilizing administrative data to accurately identify patients with COPD. Methods: Sequential logistic regression models were constructed using 9573 patients with postbronchodilator spirometry at two Veterans Affairs medical centers (2003-2007). COPD was defined as: 1) FEV1/FVC <0.70, and 2) FEV1/FVC < lower limits of normal. Model inputs included age, outpatient or inpatient COPD-related ICD-9 codes, and the number of metered does inhalers (MDI) prescribed over the one year prior to and one year post spirometry. Model performance was assessed using standard criteria. Results: 4564 of 9573 patients (47.7%) had an FEV1/FVC < 0.70. The presence of ≥1 outpatient COPD visit had a sensitivity of 76% and specificity of 67%; the AUC was 0.75 (95% CI 0.74-0.76). Adding the use of albuterol MDI increased the AUC of this model to 0.76 (95% CI 0.75-0.77) while the addition of ipratropium bromide MDI increased the AUC to 0.77 (95% CI 0.76-0.78). The best performing model included: ≥6 albuterol MDI, ≥3 ipratropium MDI, ≥1 outpatient ICD-9 code, ≥1 inpatient ICD-9 code, and age, achieving an AUC of 0.79 (95% CI 0.78-0.80). Conclusion: Commonly used definitions of COPD in observational studies misclassify the majority of patients as having COPD. Using multiple diagnostic codes in combination with pharmacy data improves the ability to accurately identify patients with COPD.Department of Veterans Affairs, Health Services Research and Development (DHA), American Lung Association (CI- 51755-N) awarded to DHA, the American Thoracic Society Fellow Career Development AwardPeer Reviewedhttp://deepblue.lib.umich.edu/bitstream/2027.42/84155/1/Cooke - ICD9 validity in COPD.pd

Peak expiratory flow rate shows a gender-specific association with vitamin D deficiency

Context: To our knowledge, no previous studies examined the longitudinal relationship between vitamin D status and pulmonary function in a population-based sample of older persons. Objective: Our objective was to examine the cross-sectional as well as the longitudinal relationship between vitamin D status and peak expiratory flow rate (PEFR) in a representative sample of the Dutch older population. Design, Setting, and Participants: Participants included men and women in the Longitudinal Aging Study Amsterdam, an ongoing cohort study in older people. Main Outcome Measure: PEFR was measured using the mini-Wright peak flow meter. Results: Men with serum 25-hydroxyvitamin D (25-OHD) levels below 10 ng/ml (25 nmol/liter) had a significantly lower PEFR in the cross-sectional analyses, and men with serum 25-OHD levels below 20 ng/ml (50 nmol/liter) had a significantly lower PEFR in the longitudinal analyses as compared with men with serum 25-OHD levels above 30 ng/ml (75 nmol/liter) (cross-sectional: β = -47.0, P = 0.01 for serum 25-OHD<10 ng/ml; longitudinal: β = -45.0, P<0.01 for serum 25-OHD<10 ng/ml; and β = -20.2, P = 0.03 for serum 25-OHD = 10-20 ng/ml in the fully adjusted models). Physical performance (β = -32.5, P = 0.08 for serum 25-OHD<10 ng/ml) and grip strength (β = -40.0, P = 0.03 for serum 25-OHD <10 ng/ml) partly mediated the cross-sectional associations but not the longitudinal associations. In women, statistically significant associations between 25-OHD and PEFR were observed in the cross-sectional analyses after adjustment for age and season of blood collection but not in the fully adjusted models or in the longitudinal analyses. Conclusions: A strong relationship between serum 25-OHD and PEFR was observed in older men, both in the cross-sectional as well as longitudinal analyses, but not in older women. The association in men could partly be explained by physical performance and muscle strength. Copyright © 2012 by The Endocrine Society

Association between cord blood 25-hydroxyvitamin D concentrations and respiratory tract infections in the first 6 months of age in a Korean population: a birth cohort study (COCOA)

PurposePrevious studies suggest that the concentration of 25-hydroxyvitamin D [25(OH)D] in cord blood may show an inverse association with respiratory tract infections (RTI) during childhood. The aim of the present study was to examine the influence of 25(OH)D concentrations in cord blood on infant RTI in a Korean birth cohort.MethodsThe levels of 25(OH)D in cord blood obtained from 525 Korean newborns in the prospective COhort for Childhood Origin of Asthma and allergic diseases were examined. The primary outcome variable of interest was the prevalence of RTI at 6-month follow-up, as diagnosed by pediatricians and pediatric allergy and pulmonology specialists. RTI included acute nasopharyngitis, rhinosinusitis, otitis media, croup, tracheobronchitis, bronchiolitis, and pneumonia.ResultsThe median concentration of 25(OH)D in cord blood was 32.0 nmol/L (interquartile range, 21.4 to 53.2). One hundred and eighty neonates (34.3%) showed 25(OH)D concentrations less than 25.0 nmol/L, 292 (55.6%) showed 25(OH)D concentrations of 25.0-74.9 nmol/L, and 53 (10.1%) showed concentrations of ≥75.0 nmol/L. Adjusting for the season of birth, multivitamin intake during pregnancy, and exposure to passive smoking during pregnancy, 25(OH)D concentrations showed an inverse association with the risk of acquiring acute nasopharyngitis by 6 months of age (P for trend=0.0004).ConclusionThe results show that 89.9% of healthy newborns in Korea are born with vitamin D insufficiency or deficiency (55.6% and 34.3%, respectively). Cord blood vitamin D insufficiency or deficiency in healthy neonates is associated with an increased risk of acute nasopharyngitis by 6 months of age. More time spent outdoors and more intensified vitamin D supplementation for pregnant women may be needed to prevent the onset of acute nasopharyngitis in infants

AROhI: An Interactive Tool for Estimating ROI of Data Analytics

The cost of adopting new technology is rarely analyzed and discussed, while it is vital for many software companies worldwide. Thus, it is crucial to consider Return On Investment (ROI) when performing data analytics. Decisions on "How much analytics is needed"? are hard to answer. ROI could guide decision support on the What?, How?, and How Much? Analytics for a given problem. This work details a comprehensive tool that provides conventional and advanced ML approaches for demonstration using requirements dependency extraction and their ROI analysis as use case. Utilizing advanced ML techniques such as Active Learning, Transfer Learning and primitive Large language model: BERT (Bidirectional Encoder Representations from Transformers) as its various components for automating dependency extraction, the tool outcomes demonstrate a mechanism to compute the ROI of ML algorithms to present a clear picture of trade-offs between the cost and benefits of a technology investment.Comment: Submitted to a conferenc