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Hasegawa, Kohei

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.

Background: Despite the research importance of rhinovirus detection in asymptomatic healthy infants, the literature remains sparse. Objective: To investigate the prevalence of respiratory syncytial virus (RSV) and rhinovirus (and its species). Methods: We conducted a cross-sectional study of 110 healthy, non-hospitalized infants without acute illness at an academic medical center from November 2013 through May 2014. We tested nasal swab specimens by using polymerase chain reaction and genetic sequencing. Results: Overall, the median age was 3.8 months (IQR 2.0–5.1 months), 56 % were male, and 90 % were born >37 weeks. RSV was detected in nasal swabs from infants (1.8 %). By contrast, rhinovirus was detected in nasal swabs from 16 infants (14.5 %). Molecular typing assay revealed rhinovirus species: six rhinovirus-A (5.5 %), one rhinovirus-B (0.9 %), eight rhinovirus-C (7.3 %), and one untypeable (0.9 %). Conclusions: In this cross-sectional study of healthy, community-based infants, RSV was rare (<2 %) in nasal swabs, while rhinovirus was detected in 14.5 % with a predominance of rhinovirus-A and -C. These finding are important for understanding the clinical significance of rhinovirus detection among infants hospitalized for bronchiolitis.

Background: We aimed to investigate mortality trends in hospitalized patients with septic shock in the US. To achieve this objective, we tested hypothesis that mortality decreased in patients identified by the code of septic shock while mortality did not change in those with septic shock identified by vasopressor use. Methods: We conducted a serial cross-sectional analysis using Nationwide Inpatient Sample database from 2005 through 2011. First, we identified all adult patients aged ≥18 years hospitalized for septic shock by the following criteria: 1) primary ICD-9 diagnosis of infection plus procedure code for vasopressor use, 2) primary ICD-9 diagnosis of infection plus septic shock in non-primary field, and 3) primary ICD-9 diagnosis of septic shock. Second, we stratified all identified patients by record of vasopressor use. The outcome of interest was year-to-year changes in the in-hospital all-cause mortality. Results: From 2005 to 2011, we identified 109,812 weighted hospitalizations with septic shock. Overall, there was a significant downward trend in in-hospital mortality (from 46 % in 2005 to 42 % in 2011; Ptrend = 0.003); the adjusted mortality also decreased significantly (OR for comparison of 2005 with 2011, 0.98; 95 % CI, 0.96–1.00; P < 0.001). In stratified analysis, the mortality trend was not significant in the subgroup with vasopressor use (from 42 % in 2005 to 40 % in 2011; Ptrend =0.57); similarly, the adjusted mortality did not change significantly (OR, 1.01; 95 % CI, 0.97–1.05; P =0.62). By contrast, there was a downward trend in mortality in the subgroup without vasopressor use (from 47 % in 2005 to 43 % in 2011; Ptrend =0.002); likewise, the adjusted mortality decreased significantly (OR, 0.97; 95 % CI, 0.95–0.99; P =0.002) Conclusions: From 2005 to 2011, we found a modest decrease in in-hospital mortality among patients identified with septic shock. However, in the subgroup with vasopressor use, we found no significant change in mortality. Our data challenge the conventional wisdom that mortality in this population has improved during the last decade. Electronic supplementary material The online version of this article (doi:10.1186/s12879-016-1620-1) contains supplementary material, which is available to authorized users.

Background: Little is known about patients who frequently visit the emergency department (ED) for acute exacerbation of chronic obstructive pulmonary disease (AECOPD). We aimed to quantify the proportion and characteristics of patients with frequent ED visits for AECOPD and associated healthcare utilization. Methods: We conducted a retrospective cohort study of adults aged ≥40 years with at least one ED visit for AECOPD between 2010 and 2011, derived from population-based all-payer data of State ED and Inpatient Databases for two large and diverse states: California and Florida. Outcome measures were frequency of ED visits for AECOPD, 30-day ED revisits, subsequent hospitalizations, near-fatal events (AECOPD involving mechanical ventilation), and charges for both ED and inpatient services (available only for Florida) during the year after the first ED visit. Results: The analytic cohort comprised 98,280 unique patients with 154,736 ED visits for AECOPD. During the 1-year period, 29.4% (95% CI, 29.1%-29.7%) of the patients had two or more (frequent) visits, accounting for 55.2% (95% CI, 54.9%-55.4%) of all ED visits for AECOPD. In the multivariable model, significant predictors of frequent ED visits were age 55–74 years (vs. 40–54 years), male sex, non-Hispanic white or black race, Medicaid insurance (vs. private), and lower median household income (all P < 0.001). At the visit-level, 12.3% of ED visits for AECOPD were 30-day revisit events (95% CI, 12.1%-12.4%). Additionally, 62.8% of ED visits for AECOPD (95% CI, 62.6%-63.0%) resulted in a hospitalization; patients with frequent ED visits comprised 55.5% (95% CI, 55.2%-55.8%) of all hospitalizations. Furthermore, 7.3% (95% CI, 7.3%-7.5%) of ED visits for AECOPD led to a near-fatal event; patients with frequent ED visits accounted for 64.4% (95% CI, 63.5%-65.3%) of all near-fatal events. Total charges for AECOPD were $1.94 billion (95% CI, $1.90-1.97 billion) in Florida; patients with frequent ED visits accounted for $1.07 billion (95% CI, $1.04-1.09 billion). Conclusions: In this large cohort study, we found that 29% had frequent ED visits for AECOPD and that lower socioeconomic status was significantly associated with a higher frequency of ED visits. Individuals with frequent ED visits for AECOPD accounted for a substantial amount of healthcare utilization and financial burden.

Purpose Recent studies propose TH2-mediated inflammation in patients with asthma–chronic obstructive pulmonary disease (COPD) overlap syndrome (ACOS). However, little is known about whether fractional exhaled nitric oxide (FeNO) differs between patients with ACOS and those with COPD alone. To address this knowledge gap, a nationally representative sample was analyzed to determine the difference in FeNO levels between patients with ACOS and those with COPD alone in the US population. Patients and methods This is a cross-sectional analysis of the National Health and Nutrition Examination Survey from 2007 through 2012. All subjects aged ≥40 years with COPD were identified. ACOS was defined as self-reported wheezing in past 12 months plus bronchodilator response (forced expiratory volume increase of >200 mL and >12%) or self-reported physician diagnosis of asthma. Results: A total of 197 subjects with COPD were identified in the National Health and Nutrition Examination Survey. Of these, 23% met the criteria of ACOS. The FeNO level was higher in subjects with ACOS compared with those with COPD alone in both unadjusted (mean 21.2 ppb vs 13.0 ppb; difference, 8.2 [95% CI, 0.2 to 16.2]; P=0.045) and adjusted (difference, 8.2 [95% CI, 0.9 to 15.5]; P=0.03) analyses. Although there was no significant difference among current smokers, the FeNO level was significantly higher in non-current smokers with ACOS than nonsmokers with COPD alone (mean 31.9 ppb vs 20.3 ppb; adjusted difference, 20.5 [95% CI, 4.4 to 36.6]; P=0.02). In a sensitivity analysis using an alternative definition of ACOS, the results did not change materially. The diagnostic value of FeNO to discriminate ACOS from COPD alone was not sufficient, with the area under the curve of 0.63 (95% CI, 0.54 to 0.72). Conclusion: By using nationally representative US data, it was found that 23% of COPD subjects met the ACOS criteria and also that the FeNO level was higher in subjects with ACOS compared with those with COPD alone, particularly in non-current smokers.

Introduction: In June 2016, the American College of Emergency Physicians (ACEP) Emergency Quality Network began its Reduce Avoidable Imaging Initiative, designed to “reduce testing and imaging with low risk patients through the implementation of Choosing Wisely recommendations.” However, it is unknown whether New England emergency departments (ED) have already implemented evidence-based interventions to improve adherence to ACEP Choosing Wisely recommendations related to imaging after their initial release in 2013. Our objective was to determine this, as well as whether provider-specific audit and feedback for imaging had been implemented in these EDs. Methods: This survey study was exempt from institutional review board review. In 2015, we mailed surveys to 195 hospital-affiliated EDs in all six New England states to determine whether they had implemented Choosing Wisely-focused interventions in 2014. Initial mailings included cover letters denoting the endorsement of each state’s ACEP chapter, and we followed up twice with repeat mailings to non-responders. Data analysis included descriptive statistics and a comparison of state differences using Fisher’s exact test. Results: A total of 169/195 (87%) of New England EDs responded, with all individual state response rates >80%. Overall, 101 (60%) of responding EDs had implemented an intervention for at least one Choosing Wisely imaging scenario; 57% reported implementing a specific guideline/policy/clinical pathway and 28% reported implementing a computerized decision support system. The most common interventions were for chest computed tomography (CT) in patients at low risk of pulmonary embolism (47% of EDs) and head CT in patients with minor trauma (45% of EDs). In addition, 40% of EDs had implemented provider-specific audit and feedback, without significant interstate variation (range: 29–55%). Conclusion: One year after release of the ACEP Choosing Wisely recommendations, most New England EDs had a guideline/policy/clinical pathway related to at least one of the recommendations. However, only a minority of them were using provider-specific audit and feedback or computerized decision support. Few EDs have embraced the opportunity to implement the multiple evidence-based interventions likely to advance the national goals of improving patient-centered and resource-efficient care.

Objectives: Emergency department (ED) visits for asthma exacerbation reflect a failure of longitudinal asthma management. However, little is known about the characteristics of patients with frequent ED visits (≥2 visits in a 1-year period). We aimed to characterise the adult patients who frequently presented to the ED for asthma exacerbation in Japan. Design: A multicentre chart review study of 23 EDs across Japan. Participants: Adults aged 18–54 years who presented to the ED with asthma exacerbation from 2009 to 2011. Outcome measures Frequency of ED visits for asthma exacerbation in a 1-year period, including the index ED visit. Results: Of the 1002 eligible patients, 218 (22%) had frequent ED visits, accounting for 48% of total ED visits for asthma exacerbation in the 1-year period. Specifically, 12% had 2 ED visits and 10% had ≥3 visits. In these patients, guideline-recommended chronic management was suboptimal. For example, among patients with ≥3 ED visits, only 63% were treated with inhaled corticosteroids and 49% were current smokers. In a multinomial logistic regression model, markers of chronic asthma severity (history of hospitalisation for asthma and use of inhaled corticosteroids) were significantly associated with a higher frequency of ED visits (both p<0.05). Conclusions: This multicentre study in Japan demonstrated that many patients are frequent ED users for asthma exacerbation. We also found that their asthma control management is suboptimal, most likely contributing to worse chronic severity and more frequent ED visits. Further dissemination and adoption of evidence-based guidelines are required to reduce asthma morbidity in this high-risk population.

Background: The airway microbiome is a subject of great interest for the study of respiratory disease. Anterior nare samples are more accessible than samples from deeper within the nasopharynx. However, the correlation between the microbiota found in the anterior nares and the microbiota found within the nasopharynx is unknown. We assessed the anterior nares and nasopharyngeal microbiota to determine (1) the relation of the microbiota from these two upper airway sites and (2) if associations were maintained between the microbiota from these two sites and two bronchiolitis severity outcomes. Results: Among 815 infants hospitalized at 17 US centers for bronchiolitis with optimal 16S rRNA gene sequence reads from both nasal swab and nasopharyngeal aspirate samples, there were strong intra-individual correlations in the microbial communities between the two sample types, especially relating to Haemophilus and Moraxella genera. By contrast, we found a high abundance of Staphylococcus genus in the nasal swabs—a pattern not found in the nasopharyngeal samples and not informative when predicting the dominant nasopharyngeal genera. While these disparities may have been due to sample processing differences (i.e., nasal swabs were mailed at ambient temperature to emulate processing of future parent collected swabs while nasopharyngeal aspirates were mailed on dry ice), a previously reported association between Haemophilus-dominant nasopharyngeal microbiota and the increased severity of bronchiolitis was replicated utilizing the nasal swab microbiota and the same outcome measures: intensive care use (adjusted OR 6.43; 95% CI 2.25–20.51; P < 0.001) and hospital length-of-stay (adjusted OR 4.31; 95% CI, 1.73–11.11; P = 0.002). Additionally, Moraxella-dominant nasopharyngeal microbiota was previously identified as protective against intensive care use, a result that was replicated when analyzing the nasal swab microbiota (adjusted OR 0.30; 95% CI, 0.11–0.64; P = 0.01). Conclusions: While the microbiota of the anterior nares and the nasopharynx are distinct, there is considerable overlap between the bacterial community compositions from these two anatomic sites. Despite processing differences between the samples, these results indicate that microbiota severity associations from the nasopharynx are recapitulated in the anterior nares, suggesting that nasal swab samples not only are effective sample types, but also can be used to detect microbial risk markers. Electronic supplementary material The online version of this article (10.1186/s40168-017-0385-0) contains supplementary material, which is available to authorized users.

Introduction: Although bronchiolitis is a common reason for infant hospitalization, significant heterogeneity persists in its management. The American Academy of Pediatrics currently recommends that inhaled albuterol not be used in routine care of children with bronchiolitis. Our objective was to identify factors associated with pre-admission (e.g., emergency department or primary care) use of albuterol among infants hospitalized for bronchiolitis. Methods: We analyzed data from a 17-center observational study of 1,016 infants (age <1 year) hospitalized with bronchiolitis between 2011–2014. Pre-admission albuterol use was ascertained by chart review, and data were available for 1,008 (99%) infants. We used multivariable logistic regression to identify infant characteristics independently associated with pre-admission albuterol use. Results: Half of the infants (n=508) received at least one albuterol treatment before admission. Across the 17 hospitals, pre-admission albuterol use ranged from 23–84%. In adjusted analysis, independent predictors of albuterol use were the following: age ≥2 months (age 2.0–5.9 months [odds ratio (OR) 2.09, 95% confidence interval (CI) {1.45–3.01}] and age 6.0–11.9 months [OR 2.89, 95% CI {1.99–4.19}]); prior use of a bronchodilator (OR 1.89, 95% CI [1.24–2.90]); and presence of wheezing documented in pre-admission chart (OR 3.94, 95% CI [2.61–5.93]). By contrast, albuterol use was less likely among those with ≥7 days since the start of breathing problem (OR 0.66, 95% CI [0.44–1.00]) and parent-reported fever (OR 0.75, 95% CI [0.58–0.96]). Conclusion: Variation in pre-admission albuterol use suggests that local practice had a strong influence on use, but that patient characteristics also influenced the decision. While we agree with current guidelines in recommending against albuterol for all infants with bronchiolitis, our understanding of possible subgroups of responders may improve through investigation of infants with the identified characteristics.

Background: Obesity and heart failure (HF) are important public health problems in the United States. Although studies have reported the association between obesity and higher chronic morbidity of HF, little is known about the relations of obesity with severity of HF exacerbation and in‐hospital mortality; therefore, we aimed to investigate the associations of obesity with severity of HF exacerbation and in‐hospital mortality. Methods and Results: This retrospective cohort study of adults hospitalized for HF exacerbation used population‐based data sets (the State Inpatient Databases) of 7 US states from 2012 to 2013. The outcomes were acute severity measures—use of positive pressure ventilation and hospital length of stay—and in‐hospital mortality. We determined the associations between obesity and these outcomes, including adjustment for sociodemographic factors and comorbidities. We identified 219 465 patients hospitalized for HF exacerbation. Of those, 37 539 (17.1%) were obese. Obese patients had a significantly higher risk of positive pressure ventilation use compared with nonobese patients (13.6% versus 8.8%), with a corresponding adjusted odds ratio of 1.61 (95% confidence interval, 1.55–1.68; P<0.001). Likewise, obese patients were more likely to have hospital length of stay of ≥4 days compared with nonobese patients (62.5% versus 56.7%), with an adjusted odds ratio of 1.40 (95% confidence interval, 1.37–1.44; P<0.001). In contrast, obese patients had significantly lower in‐hospital mortality compared with nonobese patients (1.7% versus 3.3%), with an adjusted odds ratio of 0.87 (95% confidence interval, 0.80–0.95; P=0.002). Conclusions: Based on large population‐based data sets of patients with HF exacerbation, obesity was associated with higher acute severity measures but lower in‐hospital mortality.