Associations of Fatty Liver Disease With Recovery After Traumatic Injury.

INTRODUCTION: Fatty liver disease (FLD) is associated with systemic inflammation, metabolic disease, and socioeconomic risk factors for poor health outcomes. Little is known on how adults with FLD recover from traumatic injury. METHODS: We studied adults admitted to the intensive care unit of a level 1 trauma center (2016-2020), excluding severe head injury/cirrhosis (N = 510). We measured the liver-spleen attenuation difference in Hounsfield units (HUL-S) using virtual noncontrast computerized tomography scans: none (HUL-S>1), mild (-10≤HUL-S<1), moderate/severe (HUL-S < -10). We used Cox models to examine the "hazard" of recovery from systemic inflammatory response (SIRS score 2 or higher) organ dysfunction, defined as sequential organ failure assessment score 2 or higher, and lactate clearance (<2 mmol/L) in relation to FLD. RESULTS: Fifty-one participants had mild and 29 had moderate/severe FLD. The association of FLD with recovery from SIRS differed according to whether an individual had shock on admission (hazard ratio [HR] = 0.76; 95% confidence interval [CI] 0.55-1.05 with shock; HR = 1.81; 95% CI 1.43-2.28 without shock). Compared to patients with no FLD, the hazard of lactate clearance was similar for mild FLD (HR = 1.04; 95% CI 0.63-1.70) and lower for moderate/severe FLD (HR = 0.40; 95% CI 0.18-0.89). CONCLUSIONS: FLD is common among injured adults. Associations of FLD with outcomes after shock and critical illness warrant further study.

Predicting high-intensity resuscitation needs in injured patients in the post-hemostasis phase of care following intervention.

BACKGROUND: Best resuscitation practices in the posthemostasis phase of care are poorly defined; this phase of care is characterized by a range of physiologic derangements and multiple therapeutic modalities used to address them. Using a cohort of injured patients who required an immediate intervention in the operating room or angiography suite following arrival to the emergency department, we sought to define high-intensity resuscitation (HIR) in this posthemostasis phase of care; we hypothesized that those who would require HIR could be identified, using only data available at intensive care unit (ICU) admission. METHODS: Clinical data were extracted for consecutive injured patients (2016-2019) admitted to the ICU following an immediate procedure in the operating room or angiography suite. High-intensity resuscitation thresholds were defined as the top decile of blood product (≥3 units) and/or crystalloid (≥4 L) use in the initial 12 hours of ICU care and/or vasoactive medication use between ICU hours 2 and 12. The primary outcome, HIR, was a composite of any of these modalities. Predictive modeling of HIR was performed using logistic regression with predictor variables selected using Least Absolute Shrinkage and Selection Operator (LASSO) estimation. Model was trained using 70% of the cohort and tested on the remaining 30%; model predictive ability was evaluated using area under receiver operator curves. RESULTS: Six hundred five patients were included. Patients were 79% male, young (median age, 39 years), severely injured (median Injury Severity Score, 26), and an approximately 3:2 ratio of blunt to penetrating mechanisms of injury. A total of 215 (36%) required HIR. Predictors selected by LASSO included: shock index, lactate, base deficit, hematocrit, and INR. The area under receiver operator curve for the LASSO-derived HIR prediction model was 0.82. CONCLUSION: Intensive care unit admission data can identify subsequent HIR in the posthemostasis phase of care. Use of this model may facilitate triage, nursing ratio determination, and resource allocation. LEVEL OF EVIDENCE: Therapeutic/Care Management; Level IV.

Defining Posttraumatic Sepsis for Population-Level Research.

Importance: Multiple classification methods are used to identify sepsis from existing data. In the trauma population, it is unknown how administrative methods compare with clinical criteria for sepsis classification. Objectives: To characterize the agreement between 3 approaches to sepsis classification among critically ill patients with trauma and compare the sepsis-associated risk of adverse outcomes when each method was used to define sepsis. Design, Setting, and Participants: This retrospective cohort study used data collected between January 1, 2012, and December 31, 2020, from patients aged 16 years or older with traumatic injury, admitted to the intensive care unit of a single-institution level 1 trauma center and requiring invasive mechanical ventilation for at least 3 days. Statistical analysis was conducted from August 1, 2021, to March 31, 2022. Exposure: Hospital-acquired sepsis, as classified by 3 methods: a novel automated clinical method based on data from the electronic health record, the National Trauma Data Bank (NTDB), and explicit and implicit medical billing codes. Main Outcomes and Measures: The primary outcomes were chronic critical illness and in-hospital mortality. Secondary outcomes included number of days in an intensive care unit, number of days receiving mechanical ventilation, discharge to a skilled nursing or long-term care facility, and discharge to home without assistance. Results: Of 3194 patients meeting inclusion criteria, the median age was 49 years (IQR, 31-64 years), 2380 (74%) were male, and 2826 (88%) sustained severe blunt injury (median Injury Severity Score, 29 [IQR, 21-38]). Sepsis was identified in 747 patients (23%) meeting automated clinical criteria, 118 (4%) meeting NTDB criteria, and 529 (17%) using medical billing codes. The Light κ value for 3-way agreement was 0.16 (95% CI, 0.14-0.19). The adjusted relative risk of chronic critical illness was 9.9 (95% CI, 8.0-12.3) for sepsis identified by automated clinical criteria, 5.0 (95% CI, 3.4-7.3) for sepsis identified by the NTDB, and 4.5 (95% CI, 3.6-5.6) for sepsis identified using medical billing codes. The adjusted relative risk for in-hospital mortality was 1.3 (95% CI, 1.0-1.6) for sepsis identified by automated clinical criteria, 2.7 (95% CI, 1.7-4.3) for sepsis identified by the NTDB, and 1.0 (95% CI, 0.7-1.2) for sepsis identified using medical billing codes. Conclusions and Relevance: In this cohort study of critically ill patients with trauma, administrative methods misclassified sepsis and underestimated the incidence and severity of sepsis compared with an automated clinical method using data from the electronic health record. This study suggests that an automated approach to sepsis classification consistent with Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis-3) clinical criteria is feasible and may improve existing approaches to health services and population-based research in this population.

Cross-sectional Associations of Multiracial Identity with Self-Reported Asthma and Poor Health Among American Indian and Alaska Native Adults.

INTRODUCTION: American Indian and Alaska Native (AI/AN) multiracial subgroups are underrecognized in health outcomes research. METHODS: We performed a cross-sectional analysis of Behavioral Risk Factor Surveillance System surveys (2013-2019), including adults who self-identified as AI/AN only (single race AI/AN, n = 60,413) or as AI/AN and at least one other race (multiracial AI/AN, (n = 6056)). We used log binomial regression to estimate the survey-weighted prevalence ratios (PR) and 95% confidence intervals (CI) of lifetime asthma, current asthma, and poor self-reported health among multiracial AI/AN adults compared to single race AI/AN adults, adjusting for age, obesity, and smoking status. We then examined whether associations differed by sex and by Latinx identity. RESULTS: Lifetime asthma, current asthma, and poor health were reported by 25%, 18%, and 30% of multiracial AI/AN adults and 18%, 12%, and 28% single race AI/AN adults. Multiracial AI/AN was associated with a higher prevalence of lifetime (PR 1.30, 95% CI 1.18-1.43) and current asthma (PR 1.36, 95% CI 1.21-1.54), but not poor health. Associations did not differ by sex. The association of multiracial identity with current asthma was stronger among AI/AN adults who identified as Latinx (PR 1.77, 95% CI 1.08-2.94) than non-Latinx AI/AN (PR 1.18, 95% CI 1.04-1.33), p-value for interaction 0.03. CONCLUSIONS: Multiracial AI/AN adults experience a higher prevalence of lifetime and current asthma compared to single race AI/AN adults. The association between multiracial identity and current asthma is stronger among AI/AN Latinx individuals. The mechanisms for these findings remain under-explored and merit further study.

PREHOSPITAL CRYSTALLOID RESUSCITATION: PRACTICE VARIATION AND ASSOCIATIONS WITH CLINICAL OUTCOMES.

ABSTRACT: Introduction: Although resuscitation guidelines for injured patients favor blood products, crystalloid resuscitation remains a mainstay in prehospital care. Our understanding of contemporary prehospital crystalloid (PHC) practices and their relationship with clinical outcomes is limited. Methods: The Pragmatic, Randomized Optimal Platelet and Plasma Ratios trial data set was used for this investigation. We sought to identify factors associated with PHC volume variation and hypothesized that higher PHC volume is associated with worse coagulopathy and a higher risk of acute respiratory distress syndrome (ARDS) but a lower risk of acute kidney injury (AKI). Subjects were divided into groups that received <1,000 mL PHC (PHC<1,000) and ≥1,000 mL PHC (PHC≥1,000); initial laboratory values and outcomes (ARDS and AKI risk) were summarized with medians and interquartile ranges or percentages and compared using Wilcoxon rank-sum tests and chi-square tests. The primary outcome was ARDS risk. Multivariable regression was used to characterize the association of each 500 mL aliquot of PHC with initial laboratory values and clinical outcomes. Results: PHC volume among study subjects (n = 680) varied (median, 0.3 L; interquartile range, 0-0.9 L) with weak associations demonstrated among prehospital hemodynamics, intubation, Glasgow Coma Score, and Injury Severity Score (0.008 ≤ R2 ≤ 0.09); prehospital time and enrollment site explained more variation in PHC volume with R2 values of 0.2 and 0.54, respectively. Compared with PHC<1,000, PHC≥1,000 had higher INR, PT, PTT, and base deficit and lower hematocrit and platelets. The proportion of ARDS in the PHC≥1,000 group was higher than PHC<1,000 (21% vs. 12%, P < 0.01), whereas the rate of AKI was similar between groups (23% vs. 23%, P = 0.9). In regression analyses, each 500 mL of PHC was associated with increased INR and PTT, and decreased hematocrit and platelet count (P < 0.05). Each 500 mL of PHC was associated with increased ARDS risk and decreased AKI risk (P < 0.05). Conclusion: PHC administration correlates poorly with prehospital hemodynamics and injury characteristics. Increased PHC volume is associated with greater anemia, coagulopathy, and increased risk of ARDS, although it may be protective against AKI.

Meals for Good: An innovative community project to provide healthy meals to children in early care and education programs through food bank catering.

Innovative approaches to childhood obesity prevention are warranted in early care and education (ECE) settings, since intervening early among youth is recommended to promote and maintain healthy behaviors. The objective of the Meals for Good pilot was to explore feasibility of implementing a food bank-based catering model to ECE programs to provide more nutritious meals, compared to meals brought from home (a parent-prepared model). In 2014-2015, a 12-month project was implemented by a food bank in central Florida in four privately-owned ECE programs. An explanatory sequential design of a mixed-methods evaluation approach was utilized, including a pre-post menu analysis comparing parent-prepared meals to the catered meals, and stakeholder interviews to determine benefits and barriers. The menu analysis of lunches showed daily reductions in calories, fat, and saturated fat, but an increase in sodium in catered meals when compared to parent-prepared meals. Interviews with ECE directors, teachers, parents, and food bank project staff, identified several benefits of the catered meals, including healthfulness of meals, convenience to parents, and the ECE program's ability to market this meal service. Barriers of the catered meals included the increased cost to parents, transportation and delivery logistics, and change from a 5 to a 2-week menu cycle during summer food service. This pilot demonstrated potential feasibility of a food bank-ECE program partnership, by capitalizing on the food bank's existing facilities and culinary programming, and interest in implementing strategies focused on younger children. The food bank has since leveraged lessons learned and expanded to additional ECE programs.

Safety and efficacy of ketorolac tromethamine 0.4% ophthalmic solution in post-photorefractive keratectomy patients.

PURPOSE: To evaluate the safety and analgesic efficacy of ketorolac tromethamine 0.4% ophthalmic solution in postoperative photorefractive keratectomy (PRK) patients. SETTING: Fifteen clinical sites in the eastern and southern United States. METHODS: This pooled analysis of 2 multicenter, randomized, double-masked, vehicle-controlled, parallel-group studies comprised 313 patients having unilateral PRK. After surgery, patients were treated with 1 drop of ketorolac tromethamine 0.4% ophthalmic solution (Acular(R) LS) (n = 156) or vehicle (n = 157) 4 times daily for up to 4 days. Pain intensity, pain relief, use of escape medication, and severity of ocular symptoms were assessed. Adverse events, epithelial healing, and visual acuity were recorded. RESULTS: There was significantly less pain intensity experienced by patients in the ketorolac group (P<.001). During the first 12 hours post PRK, 50% fewer patients in the ketorolac group than in the vehicle group had severe to intolerable pain (41.6% [64/154] and 84.5% [131/155], respectively). The median time to no pain was 30 hours in the ketorolac group and 54 hours in the vehicle group (P<.001, survival analysis). Ketorolac patients reported significantly greater pain relief than vehicle patients throughout the study (P<.001). Ketorolac patients used significantly less escape medication than vehicle patients for 48 hours post PRK (P< or =.008). Treatment-related adverse events occurred in 2.6% (4/156) of ketorolac patients and 6.4% (10/157) of vehicle patients. CONCLUSION: Ketorolac 0.4% ophthalmic solution is safe and effective in reducing ocular pain when used 4 times daily for up to 4 days post PRK.

Blood concentrations of cyclosporin a during long-term treatment with cyclosporin a ophthalmic emulsions in patients with moderate to severe dry eye disease.

To quantify blood cyclosporin A (CsA) concentrations during treatment with CsA topical ophthalmic emulsions, blood was collected from 128 patients enrolled in a Phase 3, multicenter, double-masked, randomized, parallel-group study of CsA eyedrops for treatment of moderate to severe dry eye disease. Patients received 0.05% CsA, 0.1% CsA, or vehicle b.i.d. for 6 months; vehicle-treated patients then crossed over to 0.1% CsA b.i.d. for 6 months. CsA concentrations were measured using a validated LC/MS-MS assay (quantitation limit = 0.1 ng/mL). No patient receiving 0.05% CsA had any quantifiable CsA in the blood (n = 96 samples). All but 7 of 128 (5.5%) trough blood samples from the 0.1% CsA group were below the quantitation limit for CsA; none exceeded 0.3 ng/mL. CsA was also below the limit of quantitation in 205 of 208 (98.6%) of serial postdose blood samples collected from 26 patients during 1 dosing interval between months 9 and 12. The highest C(max) measured, 0.105 ng/mL at 3 hours postdose, occurred in a 0.1% CsA-treated patient. These results indicate that long-term use of topical CsA ophthalmic emulsions at doses that are clinically efficacious for treating dry eye will not cause any system-wide effects.