The COVID-19 impact on STEMI disparities.

ST-segment elevation myocardial infarction (STEMI) is a significant source of morbidity and mortality. Despite guideline-driven management and increased awareness of social determinants of health, there are persistent disparities in diagnosis, management, and outcomes. The coronavirus disease 2019 (COVID-19) pandemic has greatly affected emergency department visitation, conditions and throughput. The aim of this study was to find any potential health disparities in patients who presented with STEMI during the COVID-19 pandemic by reviewing STEMI care data from April to September 2019 (pre-pandemic) and April to September 2020 (during the pandemic) for our hospital system. Patients with STEMI within 12 h of presentation were included in this study, and subdivided by age, gender, and race/ethnicity. We compared the turnaround times between emergency department arrival to intervention (electrocardiogram or catheterization) within the patient subgroups to find any notable differences. No statistically significant changes in turnaround times during either study period were found based on age, gender, or race/ethnicity for the STEMI interventions despite shifts in emergency department resources during the pandemic. This study helped assess the status quo in STEMI intervention for our health system and serves as a baseline for us to monitor gaps in care or areas of improvement. As healthcare systems institute new measures to promote equitable care, such as improving the accuracy of demographic data capture, establishing a baseline is an essential first step in evaluating the impact of these measures.

Infant Feeding Outcomes from a Culturally-Adapted Early Obesity Prevention Program for Immigrant Chinese American Parents.

OBJECTIVE: To examine whether a cultural adaptation of an early childhood obesity prevention program promotes healthy infant feeding practices. STUDY DESIGN: Prospective quasi-experimental study of a community-engaged multiphasic cultural adaptation of an obesity prevention program set at a federally qualified health center serving immigrant Chinese American parent-child dyads (N=298). In a group of historical controls, we assessed early infant feeding practices (breastfeeding, sugar-sweetened beverage intake) in 6-month-olds and then the same practices alongside early solid food feeding practices (bottle weaning, fruit, vegetable, sugary or salty snack consumption) in 12-month-olds. After implementation, we assessed these practices in an intervention cohort group at 6 and 12 months. We used cross-sectional groupwise comparisons and adjusted regression analyses to evaluate group differences. RESULTS: At 6 months, the intervention group had increased odds of no sugar-sweetened beverage intake (aOR: 5.69 [95% CI: 1.65, 19.63], p=0.006). At 12 months, the intervention group also had increased odds of no sugar-sweetened beverage intake (aOR: 15.22 [95% CI: 6.33, 36.62], p<0.001), increased odds of bottle weaning (aOR: 2.34 [95% CI: 1.05, 5.23], p=0.03), and decreased odds of sugary snack consumption (aOR: 0.36 [0.18, 0.70], p= 0.003). We did not detect improvements in breastfeeding, fruit, vegetable, or salty snack consumption. CONCLUSION: A cultural adaptation of a primary care-based educational obesity prevention program for immigrant Chinese American families with low-income is associated with certain healthy infant feeding practices. Future studies should evaluate cultural adaptations of more intensive interventions that better address complex feeding practices like breastfeeding and evaluate long-term weight outcomes.

Do regional geography and race influence management of chronic spontaneous urticaria?

Chronic spontaneous urticaria is defined as migratory evanescent pruritic blanching wheals that occur with variable frequency for 6 weeks or more, with or without accompanying angioedema. This condition affects approximately 0.1% to 1.4% of persons worldwide. Second-generation H1 antihistamines are the mainstay of management, with refractory cases often managed with an array of options, including H2 antihistamines, leukotriene receptor antagonists, glucocorticosteroids, immunosuppressive agents, and omalizumab. However, the degree of practice variation as to what treatments are prescribed is poorly understood, given that clinical care could be driven by patient preferences or lack of clarity as to best practices for refractory cases. We conducted a small, exploratory study of the role of race, ethnicity, and regional geographic distance to specialist care on chronic spontaneous urticaria prescribing practices. A small-area geographic variation in chronic spontaneous urticaria management in a large Chicago-area health care system was identified. Rates of omalizumab use varied by patient zip code, with more omalizumab prescriptions being associated with zip codes closer to the main office of an academic medical center-affiliated allergist-immunologist practice. Higher rates of omalizumab use were associated with White race in regional and patient-level analyses, though the reasons for this race-based finding are not clear.

Weight Status Change in Chinese American Children over a Ten-Year Period: Retrospective Study of a Primary Care Pediatric Population.

Weight change from childhood to adolescence has been understudied in Asian Americans. Known studies lack disaggregation by Asian subgroups. This retrospective study assessed the weight status change in 1500 Chinese American children aged 5−11 years from an urban primary care health center between 2007 and 2017. Weight status was categorized using the 2000 CDC growth charts into "underweight/normal weight" and "overweight/obese." The overweight/obesity prevalence in 2007 and 2017 were determined. McNemar's test and logistic regression were performed. The prevalence of overweight/obesity decreased from 29.9% in 2007 to 18.6% in 2017. Children who were overweight/obese at 5−11 years had 10.3 increased odds of staying overweight/obese over time (95% CI = 7.6−14.0, p < 0.001) compared to their underweight/normal weight counterparts. Of the children who were overweight/obese in 2007, 45.7% remained overweight/obese ten years later. Childhood overweight/obesity strongly predicts adult overweight/obesity in Chinese Americans. Targeted education and intervention are warranted to prevent adult obesity.

An operationally implementable model for predicting the effects of an infectious disease on a comprehensive regional healthcare system.

An operationally implementable predictive model has been developed to forecast the number of COVID-19 infections in the patient population, hospital floor and ICU censuses, ventilator and related supply chain demand. The model is intended for clinical, operational, financial and supply chain leaders and executives of a comprehensive healthcare system responsible for making decisions that depend on epidemiological contingencies. This paper describes the model that was implemented at NorthShore University HealthSystem and is applicable to any communicable disease whose risk of reinfection for the duration of the pandemic is negligible.

From Testing to Decision-Making: A Data-Driven Analytics COVID-19 Response.

In March 2020, NorthShore University Health System laboratories mobilized to develop and validate polymerase chain reaction based testing for detection of SARS-CoV-2. Using laboratory data, NorthShore University Health System created the Data Coronavirus Analytics Research Team to track activities affected by SARS-CoV-2 across the organization. Operational leaders used data insights and predictions from Data Coronavirus Analytics Research Team to redeploy critical care resources across the hospital system, and real-time data were used daily to make adjustments to staffing and supply decisions. Geographical data were used to triage patients to other hospitals in our system when COVID-19 detected pavilions were at capacity. Additionally, one of the consequences of COVID-19 was the inability for patients to receive elective care leading to extended periods of pain and uncertainty about a disease or treatment. After shutting down elective surgeries beginning in March of 2020, NorthShore University Health System set a recovery goal to achieve 80% of our historical volumes by October 1, 2020. Using the Data Coronavirus Analytics Research Team, our operational and clinical teams were able to achieve 89% of our historical volumes a month ahead of schedule, allowing rapid recovery of surgical volume and financial stability. The Data Coronavirus Analytics Research Team also was used to demonstrate that the accelerated recovery period had no negative impact with regard to iatrogenic COVID-19 infection and did not result in increased deep vein thrombosis, pulmonary embolisms, or cerebrovascular accident. These achievements demonstrate how a coordinated and transparent data-driven effort that was built upon a robust laboratory testing capability was essential to the operational response and recovery from the COVID-19 crisis.

Emergency department bounceback characteristics for patients diagnosed with COVID-19.

BACKGROUND: The global healthcare burden of COVID-19 continues to rise. There is currently limited information regarding the disease progression and the need for hospitalizations in patients who present to the Emergency Department (ED) with minimal or no symptoms. OBJECTIVES: This study identifies bounceback rates and timeframes for patients who return to the ED due to COVID-19 after initial discharge on the date of testing. METHODS: Using the NorthShore University Health System's (NSUHS) Enterprise Data Warehouse (EDW), we conducted a retrospective cohort analysis of patients who were tested positive for COVID-19 and were discharged home on the date of testing. A one-month follow-up period was included to ensure the capture of disease progression. RESULTS: Of 1883 positive cases with initially mild symptoms, 14.6% returned to the ED for complaints related to COVID-19. 56.9% of the mildly symptomatic bounceback patients were discharged on the return visit while 39.5% were admitted to the floor and 3.6% to the ICU. Of the 1120 positive cases with no initial symptoms, only four returned to the ED (0.26%) and only one patient was admitted. Median initial testing occurred on day 3 (2-5.6) of illness, and median ED bounceback occurred on day 9 (6.3-12.7). Our statistical model was unable to identify risk factors for ED bouncebacks. CONCLUSION: COVID-19 patients diagnosed with mild symptoms on initial presentation have a 14.6% rate of bounceback due to progression of illness.

Natural History of Chronic Hepatitis B Infection Among Chinese Children and Young Adults: A Single-Center Experience.

OBJECTIVES: There are limited data on the natural history of chronic hepatitis B virus (HBV) infection in Asian American children. The aim of the present study was to describe a single-center experience of chronic HBV infection in Chinese American patients in New York City. METHODS: A retrospective chart review was conducted for patients with chronic HBV infection who had pediatric visits from 2006 to 2017. Clinical and laboratory data were collected to characterize the status of HBV infection and its disease course both cross-sectionally and longitudinally. Available maternal charts were reviewed. RESULTS: Of the total 353 patients, 72 patients (20%) were US-born. Positive hepatitis B envelope antigen (HBeAg) was documented in 208 patients (58%). Three phases of chronic HBV infection were categorized for 329 patients: immune-tolerant 112 (34%), HBeAg-positive immune-active 47 (14%), and inactive carrier 82 (25%). The remaining 88 patients (27%) did not fit into a particular category with 26 of 88 patients meeting the criteria for inactive carrier except for mildly elevated alanine aminotransferase. Age and liver enzyme levels were significantly different between HBeAg-positive and HBeAg-negative groups (P < 0.05). Among 179 patients followed for ≥5 years, the spontaneous seroconversion rate was 38%. In eight patients with linked maternal data, all children completed the HBV vaccine series and seven of eight received hepatitis B immunoglobulin. All mothers were HBeAg-positive with high HBV DNA and had no anti-viral therapy during pregnancy. CONCLUSIONS: Both immune-tolerant and inactive carrier phases were common for chronic HBV infection with a spontaneous seroconversion rate of 38%. All US-born patients were born in the era of implemented universal immune-prophylaxis.

Clinical Analytics Prediction Engine (CAPE): Development, electronic health record integration and prospective validation of hospital mortality, 180-day mortality and 30-day readmission risk prediction models.

BACKGROUND: Numerous predictive models in the literature stratify patients by risk of mortality and readmission. Few prediction models have been developed to optimize impact while sustaining sufficient performance. OBJECTIVE: We aimed to derive models for hospital mortality, 180-day mortality and 30-day readmission, implement these models within our electronic health record and prospectively validate these models for use across an entire health system. MATERIALS & METHODS: We developed, integrated into our electronic health record and prospectively validated three predictive models using logistic regression from data collected from patients 18 to 99 years old who had an inpatient or observation admission at NorthShore University HealthSystem, a four-hospital integrated system in the United States, from January 2012 to September 2018. We analyzed the area under the receiver operating characteristic curve (AUC) for model performance. RESULTS: Models were derived and validated at three time points: retrospective, prospective at discharge, and prospective at 4 hours after presentation. AUCs of hospital mortality were 0.91, 0.89 and 0.77, respectively. AUCs for 30-day readmission were 0.71, 0.71 and 0.69, respectively. 180-day mortality models were only retrospectively validated with an AUC of 0.85. DISCUSSION: We were able to retain good model performance while optimizing potential model impact by also valuing model derivation efficiency, usability, sensitivity, generalizability and ability to prescribe timely interventions to reduce underlying risk. Measuring model impact by tying prediction models to interventions that are then rapidly tested will establish a path for meaningful clinical improvement and implementation.

Measuring overweight and obesity in Chinese American children using US, international and ethnic-specific growth charts.

OBJECTIVE: The aim is to determine the disparity between the overweight and obesity prevalence of Chinese American school-aged children and adolescents as measured by the Centers for Disease Control and Prevention (CDC) growth reference and the prevalence as measured by international and ethnic-specific-growth references. DESIGN: This retrospective, cross-sectional study measured overweight and obesity prevalence among a paediatric population using the CDC, International Obesity Task Force (IOTF), World Health Organization (WHO) and an ethnic Chinese growth curve. SETTING: A community health centre in New York City, USA. PARTICIPANTS: Chinese American children aged 6-17 years in 2017 (N 9160). RESULTS: The overweight prevalence was 24 % (CDC), 23 % (IOTF), 30 % (WHO) and 31 % (China). The obesity prevalence was 10 % (CDC), 5 % (IOTF), 10 % (WHO) and 10 % (China). When disaggregated by age and sex, the difference was the most prominent in girls; using the China reference compared with using the CDC reference almost doubles the overweight prevalence (school-aged: 31 v. 17 %, P < 0·001, adolescent: 27 v. 14 %, P < 0·001) and the obesity prevalence (school-aged: 11 v. 5 %, P < 0·001, adolescent: 7 v. 4 %, P < 0·001). CONCLUSIONS: Use of the CDC reference compared with the Chinese ethnic-specific reference results in lower overweight and obesity prevalence in Chinese American girls. Almost half of the girls who were overweight and half of the girls who were obese were not identified using the CDC reference. Using ethnic-specific references or ethnic-specific cut-points may help improve overweight identification for Chinese American children.

The Association of Grandparent Care with Childhood Overweight and Obesity in Chinese American Families.

BACKGROUND: Grandparents are often the caretakers of children in Chinese American families. Studies have shown that Chinese grandparents underestimate the weight of their grandchildren and associate food with increased height and strength. This study examines the association of grandparental care with weight status in Chinese American children and adolescents. METHODS: This is a cross-sectional study of 12,029 Chinese American pediatric patients ages 2-19 at a community health center in New York City in 2015. Grandparental care was defined as child care provided by at least one grandparent. Multivariable logistic regression was conducted to assess for association between having a grandparent caretaker and weight status in the age groups 2-5, 6-11, and 12-19 while adjusting for sex, place of birth, neighborhood poverty, and two-parent households. RESULTS: Approximately 12% of Chinese American children in this population had a grandparent caretaker. Children and adolescents with grandparent caretakers are more likely to be overweight than their counterparts with no grandparent caretakers at ages 6-11 (odds ratio [OR]: 1.48; 95% confidence interval [CI]: 1.23-1.79) and ages 12-19 (OR: 1.54; 95% CI: 1.18-2.02). No association was found between grandparental care and overweight in ages 2-5 nor with obesity in any age group. CONCLUSIONS: Grandparental care is associated with the weight of school-age children and adolescents. Targeted education on appropriate nutrition for the child's age is needed for grandparents who take care of children.

Update on Chinese American Childhood Obesity Prevalence in New York City.

Prevalence of overweight and obesity was measured in 12,275 Chinese American children and adolescents, ages 2-19, who were patients at a large federally qualified health center in 2015. Demographic characteristics sex, age, and birthplace were further stratified to explore disaggregated prevalence. Comparison of this 2015 cohort to an ethnically similar study cohort from the same health center in 2004 showed that the overall prevalence in overweight and obesity dropped to 21% from previously recorded 24%. US Born school-aged males continue to have the highest prevalence of overweight and obesity at 36%. School-aged children have higher odds of being overweight or obese (OR 1.61, P < 0.001; OR 1.99, P < 0.001) compared to adolescents. Although the foreign-born females had the lowest prevalence of overweight and obesity (12%), they were the only group in 2015 to have increased prevalence in overweight and obesity since 2004 (by 5.8%).

Perception of Child Weight and Feeding Styles in Parents of Chinese-American Preschoolers.

Parent perception of weight and feeding styles are associated with obesity in other racial groups but have not been explored in-depth in Chinese-American preschoolers. Cross-sectional survey of 253 Chinese-American parents with preschoolers was performed in a community clinic. Regression analysis was used to assess relationships between parental perception of weight and feeding styles. Parent under-perception of weight was common but more likely in boys than girls (χ2 = 4.91, p = 0.03). Pressuring was also greater in boys [adjusted mean difference (95% CI) 0.24 (0.004, 0.49)]. In girls, pressuring was lower for children perceived as overweight [adjusted mean difference in CFQ scores -0.75 (-1.27, -0.23)]; in boys, pressuring was high regardless of perceived child weight. Weight perceptions and feeding styles related to childhood obesity in other groups were identified in Chinese-American families. Parent under-perception of child weight and pressure to eat were more common in boys. These factors should be addressed in Chinese-American preschooler obesity prevention programs.

Direct Calculation of Protein Fitness Landscapes through Computational Protein Design.

Naturally selected amino-acid sequences or experimentally derived ones are often the basis for understanding how protein three-dimensional conformation and function are determined by primary structure. Such sequences for a protein family comprise only a small fraction of all possible variants, however, representing the fitness landscape with limited scope. Explicitly sampling and characterizing alternative, unexplored protein sequences would directly identify fundamental reasons for sequence robustness (or variability), and we demonstrate that computational methods offer an efficient mechanism toward this end, on a large scale. The dead-end elimination and A(∗) search algorithms were used here to find all low-energy single mutant variants, and corresponding structures of a G-protein heterotrimer, to measure changes in structural stability and binding interactions to define a protein fitness landscape. We established consistency between these algorithms with known biophysical and evolutionary trends for amino-acid substitutions, and could thus recapitulate known protein side-chain interactions and predict novel ones.

Prevalence of overweight and obesity in Chinese American children in New York City.

Childhood obesity has been a growing concern in recent years. The extent of obesity in various ethnic pediatric populations including Chinese Americans has not been fully explored. In this study, the prevalence of overweight and obesity in a Chinese American pediatric population (6-19 years) was determined through a chart review of 4,695 patients from a large community health center in New York City. Demographic characteristics including sex, age and immigrant status were used in a logistic regression to determine risk factors for obesity in this community. Overall, 24.6% of the children studied were overweight or obese (defined as BMI > or = 85th percentile for age and sex). Among US born boys aged 6-12 years, the combined prevalence of overweight and obesity was found to be as high as 40%. Further studies are needed to understand the complex interplay of factors that contribute to obesity in pediatric immigrant groups.