National Trends and Variation of Functional Status Deterioration in the Medically Critically Ill.

OBJECTIVES: Physical and psychologic deficits after an ICU admission are associated with lower quality of life, higher mortality, and resource utilization. This study aimed to examine the prevalence and secular changes of functional status deterioration during hospitalization among nonsurgical critical illness survivors over the past decade. DESIGN: We performed a retrospective longitudinal cohort analysis. SETTING: Analysis performed using the Cerner Acute Physiology and Chronic Health Evaluation outcomes database which included manually abstracted data from 236 U.S. hospitals from 2008 to 2016. PATIENTS: We included nonsurgical adult ICU patients who survived their hospitalization and had a functional status documented at ICU admission and hospital discharge. Physical functional status was categorized as fully independent, partially dependent, or fully dependent. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Functional status deterioration occurred in 38,116 patients (29.3%). During the past decade, functional status deterioration increased in each disease category, as well as overall (prevalence rate ratio, 1.15; 95% CI, 1.13-1.17; p < 0.001). Magnitude of functional status deterioration also increased over time (odds ratio, 1.03; 95% CI, 1.03-1.03; p < 0.001) with hematological, sepsis, neurologic, and pulmonary disease categories having the highest odds of severe functional status deterioration. CONCLUSIONS: Following nonsurgical critical illness, the prevalence of functional status deterioration and magnitude increased in a nationally representative cohort, despite efforts to reduce ICU dysfunction over the past decade. Identifying the prevalence of functional status deterioration and primary etiologies associated with functional status deterioration will elucidate vital areas for further research and targeted interventions. Reducing ICU debilitation for key disease processes may improve ICU survivor mortality, enhance quality of life, and decrease healthcare utilization.

Relationship of Apolipoproteins with Subclinical Cardiovascular Risk in Youth.

OBJECTIVE: To examine the association of apolipoproteins with arterial stiffness and carotid artery structure in children and adolescents. STUDY DESIGN: A total of 338 children and adolescents (178 female) with a mean age 13.0 ± 2.8 years were examined. Apolipoproteins (AI, AII, B100, CII, CIII, and E) were measured via human apolipoprotein magnetic bead panel. Applanation tonometry determined pulse wave velocity and ultrasound imaging measured carotid intima-media thickness. Dual X-ray absorptiometry measured total body fat percent. Linear regression models were adjusted for Tanner stage, sex, and race with further adjustments for body fat percent. Linear regression models also examined the interaction between Tanner stage and apolipoproteins. RESULTS: There was a significant positive association between pulse wave velocity and apolipoproteins: AI (0.015 m/s/10 µg/mL [CI 0.005-0.026], P = .003), AII (0.036 m/s/10 µg/mL [0.017-0.056], P < .001), B100 (0.009 m/s/10 µg/mL [0.002-0.016], P = .012), E (0.158 m/s/10 µg/mL [0.080-0.235], P < .001), and CIII:CII (0.033/µg/mL [0.014-0.052], P < .001). After we added body fat percent to the models, pulse wave velocity (PWV) remained positively associated with greater levels of apolipoproteins: AI, AII, B100, E, and CIII:CII. Both with and without the adjustment for body fat percent, there were no significant associations between any apolipoprotein and carotid intima-media thickness. There were no significant interactions between Tanner stage and apolipoproteins. CONCLUSIONS: These findings suggest that greater levels of apolipoprotein AII, E, and CIII:CII are associated with increased arterial stiffness in children and adolescents, both with and without adjusting for percent body fat. These specific apolipoproteins may be useful as biomarkers of cardiovascular risk.

Pediatric retransplantation of the liver: A prognostic scoring tool.

Few prognostic models have been created in children that receive liver retransplantation (rLT). We examined the SRTR database of 731 children that underwent second liver transplant between 2002 and 2018. Proportional hazards models using backward variable selection were used to identify recipient, donor, and surgical characteristics associated with survival. A simple prognostic scoring system or nomogram (ie, each risk factor was weighted on a five-point scale) was constructed based on the fitted model. Recipient age (P < .001), MELD/PELD (P < .001), recipient ventilated (P = .003), donor cause of death (P = .024), graft type (P = .045), first graft loss due to biliary tract complications (P = .048), and survival time of the first graft (P = .006) were significant predictors of retransplant survival. The bias-corrected Harrell's C-index for the multivariable model was 0.63. Survival was significantly different (P < .001) for those at low risk (0-4 points), medium risk (5-7 points), and high risk (8+ points). Survival was equivalent between low risk pediatric second transplant recipients and pediatric primary liver transplant recipients (P = .67) but significantly worse for medium- (P < .001) and high-risk (P < .001) recipients. With simple clinical characteristics, this scoring tool can modestly discriminate between those children at high risk and those children at low risk of poor outcomes after second liver transplant.

Contribution of Hedonic Hunger and Binge Eating to Childhood Obesity.

Background: Studies examining the association between hedonic hunger, that is, having frequent thoughts about food in the absence of an energy deficit, and obesity in youth show mixed results. This may be due to the confounding effect of binge eating, which has been associated with both hedonic hunger and obesity. The purpose of this study was to determine the extent to which hedonic hunger is associated with obesity independent of binge eating in youth. Methods: Data for this cross-sectional study were collected from youth enrolled in a larger study of cardiovascular disease and obesity. Linear regression models were used to assess the association between hedonic hunger measured by Power of Food Scale (PFS) and binge eating measured by Eating Disorder Examination-Questionnaire, on percent of the 95th BMI percentile (BMIp95). Results: Among 269 participants (mean age 12.8 years), 16.4% endorsed binge eating. PFS was positively associated with BMIp95 with a difference in percent of BMIp95 of 5.9% [95% confidence interval (1.5-10.3), p = 0.009]. However, when binge eating was added to the model, the relationship between PFS and BMIp95 was no longer significant. Conclusion: Hedonic hunger, above and beyond binge eating, may not be associated with BMI. Future research should examine whether screening for and targeting binge eating rather than hedonic hunger in weight management care may have more impact on obesity outcomes. Clinical Trial Registration number: NCT01508598.

Students' perceptions of global health competencies in the doctor of pharmacy (PharmD) curriculum.

INTRODUCTION: This study sought to determine pharmacy students' self-assessment of their level of competency in specified global health statements across various schools. It also evaluated attributes associated with competency and perception of importance, as well as explored students' perspectives on how best to incorporate global health content into pharmacy education. METHODS: Cross-sectional survey administered online to pharmacy students from three pharmacy schools in the United States. RESULTS: The self-assessed competency of pharmacy students in global health topic areas was low. Current or prior exposures outside of the PharmD curriculum to the global health content presented in the survey were significant indicators of self-assessed competency scores. Within individual participating schools, demographic characteristics such as gender, age category, speaking a non-English language, and progression through the PharmD curriculum were also significantly associated with competency scores reported. Most respondents (96%) agreed that relevant global health education should be incorporated into the pharmacy curriculum. CONCLUSIONS: Pharmacy students generally perceive global health competencies to be of great importance in practice, but acknowledge their deficiencies in this area. The current burden of global health education at the schools surveyed relies on individual student experience rather than curricular support. Ensuring that future pharmacists understand their role in global health teams and are able to achieve the necessary level of competency to function in interdisciplinary initiatives will require more strategic incorporation of relevant content into the curriculum.

Associations between paediatric fatigue and eating behaviours.

BACKGROUND: In adults, poor sleep quality is associated with increased obesogenic eating behaviours; less is known about this relationship in youth. The objectives of this study were to assess the strength of association between fatigue-related quality of life (QoL) and eating behaviours among youth and to describe the associations in participants with percent body fat (%BF) above and below the 90th percentile for sex and age. METHODS: Caregiver-reported measures of fatigue (Pediatric QoL Multidimensional Fatigue Scale) and eating behaviours (Child Eating Behaviour Questionnaire) were obtained from participants aged 8-17 years. %BF was measured by iDXA and grouped by sex- and age-specific percentiles. Multiple linear regression adjusting for age, sex and race/ethnicity was used. RESULTS: Of the 352 participants (49% male), 44.6% had %BF >90th percentile. General, sleep/rest and cognitive fatigue QoL was inversely associated with food approach behaviours: food responsiveness, enjoyment of food, emotional overeating and desire to drink. For participants with %BF >90th percentile, higher general fatigue QoL was associated with higher satiety responsiveness (0.13; 95% confidence interval [CI 0.03, 0.24]). For participants with %BF ≤90th percentile, higher general fatigue QoL was associated with less satiety responsiveness (-0.16; 95% CI [-0.31, -0.01]). CONCLUSION: Less fatigue symptoms were associated with less behaviours associated with food approach among paediatric participants. For participants with %BF >90th percentile, less symptoms of general fatigues corresponded with more satiety. Though causation has yet to be established, youth with elevated %BF should be screened for fatigue symptoms and offered counselling on sleep hygiene or a sleep medicine referral to help mitigate weight gain.

Epidemiological trends of surgical admissions to the intensive care unit in the United States.

BACKGROUND: Epidemiologic assessment of surgical admissions into intensive care units (ICUs) provides a framework to evaluate health care system efficiency and project future health care needs. METHODS: We performed a 9-year (2008-2016), retrospective, cohort analysis of all adult admissions to 88 surgical ICUs using the prospectively and manually abstracted Cerner Acute Physiology and Chronic Health Evaluation Outcomes database. We stratified patients into 13 surgical cohorts and modeled temporal trends in admission, mortality, surgical ICU length of stay (LOS), and change in functional status (FS) using generalized mixed-effects and Quasi-Poisson models to obtain risk-adjusted outcomes. RESULTS: We evaluated 78,053 ICU admissions and observed a significant decrease in admissions after transplant and thoracic surgery, with a concomitant increase in admissions after otolaryngological and facial reconstructive procedures (all p < 0.05). While overall risk-adjusted mortality remained stable over the study period; mortality significantly declined in orthopedic, cardiac, urologic, and neurosurgical patients (all p < 0.05). Cardiac, urologic, gastrointestinal, neurosurgical, and orthopedic admissions showed significant reductions in LOS (all p < 0.05). The overall rate of FS deterioration increased per year, suggesting ICU-related disability increased over the study period. CONCLUSION: Temporal analysis demonstrates a significant change in the type of surgical patients admitted to the ICU over the last decade, with decreasing mortality and LOS in selected cohorts, but an increasing rate of FS deterioration. Improvement in ICU outcomes may highlight the success of health care advancements within certain surgical cohorts, while simultaneously identifying cohorts that may benefit from future intervention. Our findings have significant implications in health care systems planning, including resource and personnel allocation, education, and surgical training. LEVEL OF EVIDENCE: Economic/decision, level IV.Epidemiologic, level IV.

Reproducibility of endothelial microparticles in children and adolescents.

Aim: We assessed reproducibility of endothelial microparticles (EMPs) enumeration among youth. Methods & results: Four microparticle (MP) indices - total MP per microliter platelet free plasma (PFP), total EMPs per microliter PFP, percent activated EMPs and percent lactadherin positive (LACT[+]) of total EMPs - were measured at two visits (baseline and 7 ± 3 days follow-up) to determine reproducibility overall and by obesity status. We examined CD31+ or CD144+ with CD41-EMP events of size 0.3-1.0 µm. No statistically significant differences were observed between visits for any of the four MP indices. The within-participant and between-participant coefficient of variation was acceptable (range: 1.13-2.37) with good intraclass-correlation coefficient for all indices except total MP per microliter (range: 0.10-1.00). Conclusion: Total EMPs per microliter PFP, percent-activated EMPs and percent LACT(+) of total EMPs are reproducible among youth.