Initiation of high-intensity drinking and subsequent substance use in young adulthood.

High-intensity drinking (HID; 10+ drinks/occasion) is associated with acute and long-term risks, including use of other substances. Earlier HID initiation is associated with high-risk alcohol use in young adulthood. Less is known about when HID initiation occurs relative to other substances and how it is associated with subsequent substance use. This study examined survey data from 468 respondents (35.5% female, 65.5% non-Hispanic white) who reported initiating HID by age 20. Weighted descriptive statistics of year of initiation for HID, marijuana, and nicotine were obtained. Weighted linear and logistic regressions examined associations between year and order of HID initiation and age 20 substance use (i.e., nicotine vaping, cigarette use, other tobacco use, marijuana use, marijuana vaping, simultaneous alcohol and marijuana use, and other illicit drug use) and alcohol use disorder (AUD) symptoms. Over half of participants initiated HID after marijuana (54.6%) and nicotine (54.4%). Later HID initiation was associated with fewer AUD symptoms and lower odds of all outcomes except marijuana and other illicit drug use. Initiating HID before marijuana was associated with lower odds of marijuana use outcomes and other illicit drug use at age 20. Initiating HID before nicotine was associated with lower odds of all substance use outcomes at age 20. Earlier HID initiation was associated with risk for subsequent substance use, but initiating HID earlier than other substances was not. Given its association with both alcohol-related outcomes and other substance use in young adulthood, earlier HID initiation is an important target for screening and intervention.

Trends in coping reasons for marijuana use among U.S. adolescents from 2016 to 2022.

OBJECTIVE: This study examines historical trends in coping reasons for marijuana use among adolescents (1976-2022) and explores sociodemographic variations in recent years (2016-2022). METHOD: Data from U.S. national samples of 12th grade adolescents in the Monitoring the Future (MTF) study were used to examine long-term trends (1976-2022, N = 43,237) and recent differences by sociodemographic characteristics (2016-2022, N = 3,816). Measures included marijuana use, coping reasons for use, and sociodemographic characteristics. RESULTS: The most prevalent coping reason across time was "relax," endorsed by 52.9% of past 12-month users. Coping reasons mostly exhibited significant increases over time. Sociodemographic factors were associated with coping reasons. Females had higher odds of using marijuana to escape problems and get through the day (vs. males). Black respondents were more likely to use marijuana to get through the day, and Hispanic respondents were more likely to use to relax (vs. White respondents). Those with lower (vs. higher) parental education were more likely to use due to anger/frustration and to escape problems. Adolescents who used marijuana frequently (vs. less often) had higher odds of endorsing all coping reasons. There was no robust evidence of interactions between sociodemographic characteristics and year. CONCLUSIONS: Results indicate a consistent increase in coping reasons for adolescent marijuana use over time, with variations based on sociodemographic characteristics. The findings highlight the importance of understanding subpopulations of adolescents who have higher risk of coping-related marijuana use.

Age- and Sex-Varying Associations Between Depressive Symptoms and Substance Use from Modal Ages 35 to 55 in a National Sample of U.S. Adults.

It is important to examine normative age-related change in substance use risk factors across the lifespan, with research focusing on middle adulthood particularly needed. The current study examined time-varying associations between depressive symptoms and alcohol, cigarette, and marijuana use from modal ages 35 to 55 in a national sample of US adults, overall and by sex. Data were obtained from 11,147 individuals in the longitudinal Monitoring the Future study. Participants were in 12th grade (modal age 18) in 1976-1982 and (for the data reported in this study) were surveyed again at modal ages 35 (in 1993-1999), 40, 45, 50, and 55 (in 2013-2019). Weighted time-varying effect modeling was used to examine age-related change in associations among depressive symptoms, any and heavy use of cigarettes, alcohol, and marijuana. Across midlife, greater depressive symptoms were associated with decreased odds of any alcohol use during the 40 s and 50 s, but with increased odds of binge drinking from ages 35-40, and-at most ages-any and pack + cigarette use and any and frequent marijuana use. The association between depressive symptoms and substance use was generally similar for men and women. Results highlight the increased risk for binge drinking, smoking, and marijuana with higher levels of depressive symptoms and underscore the importance of screening and interventions for depressive symptoms and substance use in midlife.

Prevalence and risk factors for delirium in critically ill patients with COVID-19 (COVID-D): a multicentre cohort study.

BACKGROUND: To date, 750 000 patients with COVID-19 worldwide have required mechanical ventilation and thus are at high risk of acute brain dysfunction (coma and delirium). We aimed to investigate the prevalence of delirium and coma, and risk factors for delirium in critically ill patients with COVID-19, to aid the development of strategies to mitigate delirium and associated sequelae. METHODS: This multicentre cohort study included 69 adult intensive care units (ICUs), across 14 countries. We included all patients (aged ≥18 years) admitted to participating ICUs with severe acute respiratory syndrome coronavirus 2 infection before April 28, 2020. Patients who were moribund or had life-support measures withdrawn within 24 h of ICU admission, prisoners, patients with pre-existing mental illness, neurodegenerative disorders, congenital or acquired brain damage, hepatic coma, drug overdose, suicide attempt, or those who were blind or deaf were excluded. We collected de-identified data from electronic health records on patient demographics, delirium and coma assessments, and management strategies for a 21-day period. Additional data on ventilator support, ICU length of stay, and vital status was collected for a 28-day period. The primary outcome was to determine the prevalence of delirium and coma and to investigate any associated risk factors associated with development of delirium the next day. We also investigated predictors of number of days alive without delirium or coma. These outcomes were investigated using multivariable regression. FINDINGS: Between Jan 20 and April 28, 2020, 4530 patients with COVID-19 were admitted to 69 ICUs, of whom 2088 patients were included in the study cohort. The median age of patients was 64 years (IQR 54 to 71) with a median Simplified Acute Physiology Score (SAPS) II of 40·0 (30·0 to 53·0). 1397 (66·9%) of 2088 patients were invasively mechanically ventilated on the day of ICU admission and 1827 (87·5%) were invasively mechanical ventilated at some point during hospitalisation. Infusion with sedatives while on mechanical ventilation was common: 1337 (64·0%) of 2088 patients were given benzodiazepines for a median of 7·0 days (4·0 to 12·0) and 1481 (70·9%) were given propofol for a median of 7·0 days (4·0 to 11·0). Median Richmond Agitation-Sedation Scale score while on invasive mechanical ventilation was -4 (-5 to -3). 1704 (81·6%) of 2088 patients were comatose for a median of 10·0 days (6·0 to 15·0) and 1147 (54·9%) were delirious for a median of 3·0 days (2·0 to 6·0). Mechanical ventilation, use of restraints, and benzodiazepine, opioid, and vasopressor infusions, and antipsychotics were each associated with a higher risk of delirium the next day (all p≤0·04), whereas family visitation (in person or virtual) was associated with a lower risk of delirium (p<0·0001). During the 21-day study period, patients were alive without delirium or coma for a median of 5·0 days (0·0 to 14·0). At baseline, older age, higher SAPS II scores, male sex, smoking or alcohol abuse, use of vasopressors on day 1, and invasive mechanical ventilation on day 1 were independently associated with fewer days alive and free of delirium and coma (all p<0·01). 601 (28·8%) of 2088 patients died within 28 days of admission, with most of those deaths occurring in the ICU. INTERPRETATION: Acute brain dysfunction was highly prevalent and prolonged in critically ill patients with COVID-19. Benzodiazepine use and lack of family visitation were identified as modifiable risk factors for delirium, and thus these data present an opportunity to reduce acute brain dysfunction in patients with COVID-19. FUNDING: None. TRANSLATIONS: For the French and Spanish translations of the abstract see Supplementary Materials section.

A risk model for addictive behaviors in adolescents: interactions between personality and learning.

BACKGROUND AND AIMS: To determine whether transdiagnostic risk, represented as elevations in one high-risk personality trait, interacts with behavior-specific risk, represented as elevated expectancies for reinforcement from either drinking or smoking, to account partly for early adolescent drinking and smoking behavior. DESIGN: Multiple regression analysis. SETTING: Twenty-three public schools in two school systems in the United States. PARTICIPANTS: A sample of 1897 adolescents tested in the spring of 5th, 6th, 7th, 8th and 9th grades. MEASUREMENTS: Transdiagnostic risk was measured as negative urgency, the tendency to act rashly when distressed, using the UPPS-P child version. Drinking-specific and smoking-specific risk were measured as expectancies for reinforcement from drinking and smoking, using the Memory Model-Based Expectancy Questionnaire (alcohol) and the Adolescent Smoking Consequences Questionnaire (smoking). FINDINGS: There was consistent concurrent prediction from the interactions of (a) negative urgency and alcohol reinforcement expectancies to early adolescent drinking and (b) negative urgency and smoking reinforcement expectancies to early adolescent smoking, above and beyond prediction from the main effects of those variables. In each case, expectancies were more predictive at higher levels of negative urgency. Incremental R2 values for main effects ranged from 0.07 to 0.26, and for interactions ranged from 0.01 to 0.03. Prospectively, the main effects predicted subsequent behavior but the interaction effects did not, except in one case. CONCLUSIONS: Among elementary and high school students in the United States, the joint effects of negative urgency and behavior-specific expectancies help to explain drinking and smoking behavior. Joint elevations on the trait and the learning variable account for drinking and smoking behavior beyond the main effects of each predictor. However, there is reason to doubt whether the joint effects predict subsequent increases in drinking and smoking beyond the main effects of those variables.

Nutrition Support for Critically Ill Patients With Cancer.

Oncology patients often experience the classic signs of malnutrition-weight loss as well as fat and muscle wasting, which have been associated with poor tolerance to treatment and increased morbidity and mortality. Nutrition status may be an important factor in determining tolerance to treatment and outcomes associated with it. Thus, identification of those with preexisting malnutrition or who are at risk for developing malnutrition is crucial not only at time of cancer diagnosis but also throughout the treatment course so that nutrition interventions may be implemented to prevent development or worsening of malnutrition in this high-risk population. These patients often have extremely complicated hospital courses due to the aggressive nature of the disease and treatment, leading to intensive care unit admission and periods of critical illness. Critical illness is associated with catabolism, extreme stress on the body, and a state of systemic inflammation. During critical illness, it is important to provide adequate nutrition to prevent further break down of lean muscle mass and oxidative cellular injury and to regulate favorable immune responses. The purpose of this review is to discuss the importance of nutrition screening and assessment for the critically ill patient with cancer; to appropriately identify those at risk for, or who have developed, malnutrition; and to provide appropriate interventions to optimize nutrition status. This review also discusses the complications and difficulties associated with feeding this patient population and offers nutrition support recommendations.

Association between elementary school personality and high school smoking and drinking.

BACKGROUND AND AIMS: Among US high school students, alcohol consumption and cigarette smoking are associated with numerous concurrent and future harms. We tested whether multiple elementary school personality dispositions to behave impulsively can predict these addictive behaviors invariably across gender and race. DESIGN AND SETTING: This longitudinal design involved testing whether individual differences on impulsigenic traits in elementary school predicted drinking and smoking 4 years later in high school in 23 public schools in Kentucky, USA. PARTICIPANTS: A total of 1897 youth, mean age 10.33 at wave 1, drawn from urban, rural and suburban backgrounds. MEASUREMENTS: Drinking and smoking frequency were assessed by single-item questions. The key predictors were impulsigenic traits measured with the UPPS-P Child Version impulsive behavior scale. Important covariates included were pubertal status, depression, negative affect and positive affect; each was assessed by self-report. FINDINGS: Three personality traits measured in 5th grade, each representing different dispositions to engage in impulsive behavior, predicted drinking and smoking in 9th grade above and beyond other risk factors and 5th grade drinking and smoking. Specifically, urgency (b = 0.10, 0.13), sensation-seeking (b = 0.13, 0.07) and low conscientiousness (b = 0.14, 0.11) each uniquely predicted both high school drinking and smoking, respectively. There was no evidence that any trait predicted either outcome more strongly than the other traits, nor was there evidence that predictive results varied by gender or race. CONCLUSIONS: Three personality traits (urgency, sensation-seeking and low conscientiousness), when measured in 11-year-old children, predict those children's drinking and smoking behavior individually at age 15. The effects are invariant across gender and race.

Differentiating Sarcopenia and Cachexia Among Patients With Cancer.

Patients with cancer are at an increased risk for muscle loss via 2 distinct mechanisms: sarcopenia, defined as the age-associated decrease in muscle mass related to changes in muscle synthesis signaling pathways, and/or cachexia, defined as cytokine-mediated degradation of muscle and adipose depots. Both wasting disorders are prevalent; among patients with cancer, 15%-50% are sarcopenic and 25%-80% are cachectic. Muscle mass may be difficult to quantify in overweight/obese individuals. Often, overweight/obese patients with cancer are assumed to be normally nourished when in fact severe muscle depletion may be present. No universally accepted treatment exists for preventing or reversing sarcopenia or cachexia in patients with cancer. Current treatment options are limited to nutrition therapy and exercise, which may lead to difficulties in adherence during cancer treatment. Future treatments may provide pharmaceutical therapy that targets muscle degradation and synthesis pathways. There is a need to determine a multimodal treatment plan for muscle depletion to improve quality of life, survival, and therapy complications in patients with cancer.

Evaluation of Pain, Dyspnea, and Goals of Care Among Adults With Cystic Fibrosis: A Comprehensive Palliative Care Survey.

BACKGROUND: Palliative care is increasingly important in the care of adults with cystic fibrosis (CF). Symptoms such as pain and dyspnea are prevalent, yet severity may be underestimated. Little information is available to describe patient preferences for end-of-life care (EOLC). The objective of this study was to describe patient perceptions about pain, dyspnea, and advance care planning. METHODS: We developed a survey to assess pain, dyspnea, and EOLC in adults with CF. Questions were compiled and adapted from existing tools. The survey was administered to all patients in a single adult CF care center. Descriptive data were compiled as counts (proportions) and median (25th and 75th percentile). Mann Whitney U test was used to determine differences between individuals who experienced pain and dyspnea. A P value of .05 was utilized to determine significance. RESULTS: Thirty-seven of 43 surveys were returned. Twenty-four percent reported chronic pain. Patients who reported pain with airway clearance had lower lung function (predicted forced expiratory volume in 1 [FEV1] 42% vs 65%, P < .05) and body mass index (19.6 vs 22.3, P < .05) than patients without pain. Those reporting dyspnea at rest had lower median FEV1 (28% vs 61%, P < .05). Patients with lower lung function are more likely to have considered end-of-life decisions (73% vs 31%, P < .05). CONCLUSION: Pain and dyspnea are common among adults with CF. Few had an advance directive in place, but most are open to discussing EOLC issues. Results of this single-center study may not represent the entire population, thus a multicenter investigation should be pursued.

Prevalence of Sarcopenia and Associated Outcomes in the Clinical Setting.

Sarcopenia refers to age-associated decrease in muscle mass and function. The condition was originally described in the elderly, but emerging evidence suggests that it is also a concern among the chronically ill nonelderly. Currently there are a number of definitions for diagnosing sarcopenia; however, in the clinical setting, abdominal computed tomography (CT) scans completed for diagnostic purposes can be utilized to identify CT-defined sarcopenia. Recent studies suggest that prevalence of CT-defined sarcopenia is high among chronically ill patients, ranging from 15%-50% in patients with cancer, 30%-45% with liver failure, and 60%-70% for critically ill patients in the intensive care unit. Depleted muscle mass is associated with infectious complications, prolonged duration of mechanical ventilation, longer hospitalization, greater need for rehabilitation care after hospital discharge, and higher mortality. In consideration of the growing population of older adults with multiple comorbidities, more research is needed to identify sarcopenia and develop interventions that are directed at attenuating or reversal muscle loss.

Utilizing multiple methods to classify malnutrition among elderly patients admitted to the medical and surgical intensive care units (ICU).

BACKGROUND & AIMS: The nutritional status of elderly patients requiring ICU admission is largely unknown. This study evaluated the prevalence of malnutrition in elderly patients (>65 years) admitted to the surgical and medical ICUs, agreement between assessment techniques and associations between malnutrition and adverse outcomes. METHODS: For this prospective cohort, nutritional status was classified concurrently using the Mini Nutrition Assessment (MNA), Subjective Global Assessment (SGA), Nutrition Risk Score 2002 (NRS 2002) and MNA-short form (MNA-SF). Demographic and relevant medical information were collected from the medical record prior to the nutrition interview and/or following hospital discharge. Descriptive statistics, inter-rater agreement and regression analyses were conducted. RESULTS: The average patient was 74.2 (±6.8) years of age with a mean APACHE II score of 11.9 (±3.6). Malnutrition was prevalent in 23-34% of patients (n = 260) with excellent agreement between raters. Compared to MNA, NRS 2002 had the highest sensitivity, while SGA and MNA-SF had higher specificity. Malnutrition at ICU admission was associated with longer hospital LOS, a lower propensity for being discharged home and a greater need for hospice care or death at discharge (all p values <0.05). These relationships were diminished when controlling for severity of illness. CONCLUSIONS: Future work in this elderly population needs to explore the role of disease acuity, inflammation and body composition in the nutrition assessment process and in the examination of outcomes.

Assessing the influence of registered dietitian order-writing privileges on parenteral nutrition use.

Previous studies have examined the influence of a nutrition support team on parenteral nutrition (PN) use; however, the influence of registered dietitian (RD) order-writing privileges on appropriate PN use has yet to be reported. A retrospective cohort was conducted at a single tertiary care urban academic medical center to compare adult PN use before RD order-writing privileges (January 1, 2003 to December 31, 2004, pre-privileges) to after RD order-writing privileges (January 1, 2006 to December 31, 2007, post-privileges). RD order-writing privileges were obtained June 2005; PN patients during the washout period (January 1, 2005 to December 31, 2005) were not included. Descriptive statistics were conducted (N=1,965 patients). Although total hospital admissions increased from the pre-privileges to post-privileges periods (P<0.0001), overall PN use decreased from 1,080 patients during the pre-privileges period to 885 patients during the post-privileges period (P<0.0001). Inappropriate PN use decreased from 482 (45%) to 240 (27%) patients (P<0.0001) during the pre- and post-privileges periods, respectively. Among inappropriate PN use, there was a decrease in PN administration for patients with poor oral intake (130 to 41 patients), pancreatitis (78 to 26 patients), intractable nausea and vomiting (68 to 23 patients), and mucositis (56 to 18 patients; all Ps<0.0003), reflecting a 20% cost savings for PN. No significant differences were found in hospital length of stay, admissions to intensive care units, or other infectious complications between the two periods. RDs with order-writing privileges can decrease inappropriate PN use and costs in a hospital setting. Future studies should continue to highlight the influence of RDs in these advanced practice roles, as well as other members of the nutrition support team, especially with regard to nutrition support delivery and patient outcomes.