Validation of "Personal Protective Equipment Conservation Strategies Tool" to Predict Consumption of N95s, Facemasks, and Gowns During Pandemic-Related Shortages.

We sought to prospectively validate a model to predict the consumption of personal protective equipment in a pediatric emergency department during the COVID-19 pandemic. We developed the Personal Protective Equipment Conservation Strategies Tool, a Monte Carlo simulation model with input parameters defined by members of our emergency department personal protective equipment task force. Inputs include different conservation strategies that reflect dynamic reuse policies. Over the course of 4 consecutive weeks in April and May 2020, we used the model to predict the consumption of N95 respirators, facemasks, and gowns in our emergency department based on values for each input parameter. At the end of each week, we calculated the percent difference between actual consumption and predicted consumption based on model outputs. Actual consumption of personal protective equipment was within 20% of model predictions for each of the 4 consecutive weeks for N95s (range, -16.3% to 16.1%) and facemasks (range, -7.6% to 13.1%), using "maximum conservation" and "high conservation" strategies, respectively. Actual consumption of gowns was 11.8% less than predicted consumption for Week 1, gown resupply data were unavailable on Weeks 2-4. The Personal Protective Equipment Conservation Strategies Tool was prospectively validated for "maximum conservation" and "high conservation" models, with actual consumption within 20% of model predictions.

Factors associated with clinical severity in emergency department patients presenting with symptomatic SARS-CoV-2 infection.

OBJECTIVE: To measure the association of race, ethnicity, comorbidities, and insurance status with need for hospitalization of symptomatic emergency department patients with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection. METHODS: This study is a cohort study of symptomatic patients presenting to a single emergency department (ED) with laboratory-confirmed SARS-CoV-2 infection from March 7-August 9, 2020. We collected patient-level information regarding demographics, insurance status, comorbidities, level of care, and mortality using a structured chart review. We compared characteristics of patients categorized by (1) home discharge, (2) general hospital ward admission, and (3) intensive care unit (ICU) admission or death within 30 days of the index visit. Univariate and multivariable logistic regression analyses were performed to report odds ratios (OR) and 95% confidence intervals (95% CI) between hospital admission versus ED discharge home and between ICU care versus general hospital ward admission. RESULTS: In total, 994 patients who presented to the ED with symptoms were included in the analysis with 551 (55.4%) patients discharged home, 314 (31.6%) patients admitted to the general hospital ward, and 129 (13.0%) admitted to the ICU or dying. Patients requiring admission were more likely to be Black or to have public insurance (Medicaid and/or Medicare). Patients who were admitted to the ICU or dying were more likely aged ≥ 65 years or male. In multivariable logistic regression, old age, public insurance, diabetes, hypertension, obesity, heart failure, and hyperlipidemia were independent predictors of hospital admission. When comparing those who needed ICU care versus general hospital ward admission in univariate logistic regression, patients with Medicaid (OR 2.4, 95% CI 1.2-4.6), Medicare (OR 4.2, 95% CI 2.1-8.4), Medicaid and Medicare (OR 4.3, 95% CI 2.4-7.7), history of chronic obstructive pulmonary disease (OR 2.2, 95% CI 1.2-4.2), hypertension (OR 1.7, 95% CI 1.1-2.7), and heart failure (OR 2.6, 95% CI 1.4-4.7) were more likely to be admitted into the ICU or die; Black (OR 1.1, 95% CI 0.4-2.9) and Hispanic/Latino (OR 1.0, 95% CI 0.6-1.8) patients were less likely to be admitted into the ICU; however, the associations were not statistically significant. In multivariable logistic regression, old age, male sex, public insurance, and heart failure were independent predictors of ICU care/death. CONCLUSION: Comorbidities and public insurance are predictors of more severe illness for patients with SARS-CoV-2. This study suggests that the disparities in severity seen in COVID-19 among Black patients may be attributable, in part, to low socioeconomic status and chronic health conditions.

The youth e-cigarette epidemic: New estimates of JUUL Labs' revenue from youth users in the US.

INTRODUCTION: Past 30-day e-cigarette use increased by 78% among high school students from 2017 to 2018, an increase attributable to pod-style devices. JUUL Labs (JUUL) insists they do not market their product to teenagers. We created several scenarios to estimate the percentages of JUUL's net revenue from adults and youth in the US in 2018. METHODS: We used the number of youth (aged 12-17 years) and adults (aged ≥18 years) who reported using JUUL in the nationally representative Population Assessment of Tobacco and Health (PATH) Study wave 4 (Dec 2016-Jan 2018) to estimate the youth proportion of JUUL users. As a sensitivity analysis, we also used data from the nationally representative Truth Longitudinal Cohort (TLC) study to estimate the youth proportion of JUUL users. Based on this percentage, we then applied several scenarios to estimate JUUL's net revenue from youth in the US in 2018. RESULTS: From the PATH Study, 31% of JUUL users were youth (aged 12-17 years). In the TLC study, 30% of current JUUL users were aged 15-17 years. Given that JUUL's net revenue was $1.3 billion in 2018, we calculated that JUUL made between $130 million and $650 million of its net revenue from youth, depending on consumption scenarios. CONCLUSIONS: A substantial proportion of JUUL's profits in 2018 were a result of use by youth. It could be required that all e-cigarette companies actively ensure that use by youth is below a pre-determined small fraction of their sales, requiring that a high penalty be paid by those that fail to do so.

Triple threat: New presentation with diabetic ketoacidosis, COVID-19, and cardiac arrhythmias.

Patients with diabetes have increased susceptibility to infection with Severe acute respiratory syndrome-coronavirus 2 and increased morbidity and mortality from Coronavirus disease 2019 (COVID-19) infection. Mortality from COVID-19 is sometimes caused by cardiac arrhythmias. Electrolyte disturbances in patients with diabetic ketoacidosis (DKA) can increase the risk of cardiac arrhythmias. Despite these correlations, little has been reported about the co-incidence of these three conditions: COVID-19, DKA and cardiac arrhythmias. In this case report we describe two children with COVID-19, new-onset DKA and cardiac arrhythmias. These cases emphasize the importance of close cardiac and electrolyte monitoring in patients with COVID-19 infection.

Firearms Injuries Involving Young Children in the United States During the COVID-19 Pandemic.

OBJECTIVES: Increased rates of firearm ownership, school closures, and a suspected decrease in supervision during the coronavirus disease 2019 (COVID-19) pandemic place young children at increased risk of firearm injuries. We measured trends in firearm injuries in children and inflicted by children discharging a firearm during the pandemic and correlated these changes with a rise in firearm acquisition. METHODS: In this cross-sectional study with an interrupted time series analysis, we used multiyear data from the Gun Violence Archive. We compared trends in (1) firearm injuries in children younger than 12 years old and (2) firearm injuries inflicted by children younger than 12 years old during the pre-COVID-19 period (March to August in the years 2016-2019) and during the first 6 months of the COVID-19 pandemic (March 2020 to August 2020). Linear regression models were developed to evaluate the relationship between firearm injuries and new firearm acquisitions. RESULTS: There was an increased risk of (1) firearm injuries in young children (relative risk = 1.90; 95% confidence interval 1.58 to 2.29) and (2) firearm injuries inflicted by young children (relative risk = 1.43; 95% confidence interval 1.14 to 1.80) during the first 6 months of the COVID-19 pandemic as compared to the pre-COVID-19 study period. These increased incidents correlate with an increase in new firearm ownership (P < .03). CONCLUSIONS: There has been a surge in firearm injuries in young children and inflicted by young children during the first 6 months of the COVID-19 pandemic. There is an urgent and critical need for enactment of interventions aimed at preventing firearm injuries and deaths involving children.

Results of Testing Children for Severe Acute Respiratory Syndrome Coronavirus-2 Through a Community-based Testing Site.

OBJECTIVE: To describe the demographics, clinical features, and test results of children referred from their primary provider for severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) in the community setting. STUDY DESIGN: Retrospective cross-sectional study of children ≤22 years of age who were tested for SARS-CoV-2 at a community-based specimen collection site in Washington, DC, affiliated with a large children's hospital between March 21 and May 16, 2020. RESULTS: Of the 1445 patients tested at the specimen collection site for SARS-CoV-2 virus, 408 (28.2%) had a positive polymerase chain reaction test. The daily positivity rate increased over the study period, from 5.4% during the first week to a peak of 47.4% (Ptrend < .001). Patients with fever (aOR, 1.7; 95% CI, 1.3-2.3) or cough (aOR, 1.4; 95% CI, 1.1-1.9) and those with known contact with someone with confirmed SARS-CoV-2 infection (aOR, 1.6; 95% CI, 1.0-2.4.) were more likely have a positive test, but these features were not highly discriminating. CONCLUSIONS: In this cohort of mildly symptomatic or well children and adolescents referred to a community drive-through/walk-up SARS-CoV-2 testing site because of risk of exposure or clinical illness, 1 in 4 patients had a positive test. Children and young adults represent a considerable burden of SARS-CoV-2 infection. Assessment of their role in transmission is essential to implementing appropriate control measures.