Efficacy of Bacillus subtilis probiotic in preventing necrotic enteritis in broilers: a systematic review and meta-analysis.

Probiotics can enhance broiler chicken health by improving intestinal microbiota, potentially replacing antibiotics. They protect against bacterial diseases like necrotic enteritis (NE) in poultry. Understanding their role is crucial for managing bacterial diseases, including NE. This study conducted a meta-analysis to assess the effects of Bacillus subtilis probiotic supplementation on feed conversion ratio (FCR), NE lesion score, and mortality. Additionally, a systematic review analysed gut microbiota changes in broilers challenged with Clostridium perfringens with or without the probiotic supplementation. Effect sizes from the studies were estimated in terms of standardized mean difference (SMD). Random effect models were fitted to estimate the pooled effect size and 95% confidence interval (CI) of the pooled effect size between the control [probiotic-free + C. perfringens] and the treatment [Bacillus subtilis supplemented + C. perfringens] groups. Overall variance was computed by heterogeneity (Q). The meta-analysis showed that Bacillus subtilis probiotic supplementation significantly improved FCR and reduced NE lesion score but had no effect on mortality rates. The estimated overall effects of probiotic supplementation on FCR, NE lesion score and mortality percentage in terms of SMD were -0.91 (CI = -1.34, -0.49; P < 0.001*); -0.67 (CI = -1.11, -0.22; P = 0.006*), and -0.32 (CI = -0.70, 0.06; P = 0.08), respectively. Heterogeneity analysis indicated significant variations across studies for FCR (Q = 69.66; P < 0.001*) and NE lesion score (Q = 42.35; P < 0.001*) while heterogeneity was not significant for mortality (Q = 2.72; P = 0.74). Bacillus subtilis probiotic supplementation enriched specific gut microbiota including Streptococcus, Butyricicoccus, Faecalibacterium, and Ruminococcus. These microbiotas were found to upregulate expression of various genes such as TJ proteins occluding, ZO-1, junctional adhesion 2 (JAM2), interferon gamma, IL12-ß and transforming growth factor-ß4. Moreover, downregulated mucin-2 expression was involved in restoring the intestinal physical barrier, reducing intestinal inflammation, and recovering the physiological functions of damaged intestines. These findings highlight the potential benefits of probiotic supplementation in poultry management, particularly in combating bacterial diseases and promoting intestinal health.

Outcomes associated with antibiotic administration for isolated maternal fever in labor.

BACKGROUND: The American College of Obstetricians and Gynecologists currently recommends that antibiotic treatment should be considered for women with isolated maternal fevers during labor. However, there is little known about the maternal and neonatal impact of antibiotic treatment in this scenario. OBJECTIVE: We sought to assess the outcomes in women with a nonsustained, isolated maternal fever treated with antibiotics and compare it with expectant management. STUDY DESIGN: This was a retrospective cohort study of laboring women with a singleton gestation at term and a single temperature of between 38.0°C and 38.9°C without other evidence of infection (leukocytosis >15,000/mm3, fetal tachycardia, malodorous amniotic fluid, suspected alternate source of infection) at a tertiary teaching hospital. A contemporaneously maintained, validated obstetrical database was used to identify women for our cohort. Women with rheumatologic or renal disease, nongestational diabetes, preterm labor, placental abruption, vaginal bleeding, HIV, malpresentation, and fetal anomalies were excluded. The primary outcome was a postpartum fever above 38.0°C. Secondary maternal outcomes were treatment for postpartum endometritis, uterine atony, postpartum hemorrhage, admission to the intensive care unit, and postpartum length of stay. Secondary neonatal outcomes were neonatal intensive care unit admission, 5-minute Apgar score of <7, 5-minute Apgar score of <4, neonatal intensive care unit length of stay, and neonatal antibiotic administration. The results were compared using univariable and multivariable analyses. RESULTS: From January 1, 2015, to December 31, 2018, 359 women were identified; 85 received antibiotics and 274 did not. The baseline characteristics were similar between the groups, except for gestational age at the time of delivery (39.2 weeks vs 39.5 weeks for the antibiotic and no antibiotic groups, respectively; P=.02). The incidence in postpartum fever showed a downward trend in the antibiotic group (10.59% for the antibiotic group vs 18.98% for the no antibiotic group; P=.07). Significantly fewer women in the antibiotic group were treated for postpartum endometritis (3.53% vs 11.31%; P=.03). Neonatal intensive care unit admission and neonatal antibiotic administration rates were higher in the antibiotic group (41.18% vs 17.88%; P<.001 and 36.47% vs 12.41%; P<.001, respectively). The incidence of 5-minute Apgar score of <7 was higher in the antibiotic group (8.25% vs 2.19%; P=.016). After controlling for age, gestational age, body mass index, group B streptococci status, delivery method, parity, administration of epidural, and receipt of acetaminophen, the odds for postpartum fever were reduced by a factor of 0.42 (95% confidence interval, 0.18-0.99) among women who received antibiotics when compared with those who did not receive antibiotics. Outcome results are presented in Table 2. CONCLUSION: Although there was a lower rate of treatment for endometritis among women who received antibiotics for a single isolated maternal fever, there was a higher rate of neonatal intensive care unit admissions and 5-minute Apgar score of <7. This indicates that there likely is maternal benefit associated with antibiotic use, however, there are concerns about the neonatal risk.

Utilization of an ICU Severity of Illness Scoring System to Triage Patients With ST-Elevation Myocardial Infarction.

OBJECTIVE: To subjectively identify low-risk ST-elevation myocardial infarction (STEMI) patients and triage this low-risk population to an intermediate level of care. BACKGROUND: Many patients with STEMI are admitted to the intensive care unit (ICU), however, a large portion do not merit ICU admission. We sought to examine whether, among post-STEMI patients admitted to the ICU, if an easily obtainable subjective scoring system could predict low-risk patients and safely triage them to an intermediate level of care. METHODS: Retrospective observational study at Christiana Hospital, a 900-bed regional referral center. Data were defined by the ACTION Registry and CathPCI Registry. Acute Physiology and Chronic Health Evaluation (APACHE) predictions were retrieved for all patients with STEMI and were analyzed for complications, length of stay, and inhospital mortality. We then examined subjective criteria to triage patients with STEMI out of the ICU. RESULTS: Among 253 patients with STEMI, 179 (70.75%) were classified as low risk (intermediate level care appropriate) and 74 (29.25%) were classified as high risk (ICU appropriate). The mean age was 64.95 years. The APACHE III score was right skewed with a mean of 36.97 and a median of 31. There was a significant difference between the APACHE III score of low-risk patients and the APACHE III score of high-risk patients (P < .001). CONCLUSION: In conclusion, patients characterized as low risk, as defined by our criteria, had low APACHE III scores and a low likelihood of complications post-STEMI. This low-risk population could potentially be admitted to an intermediate level of care, avoiding the ICU altogether.

Early-Life Digital Media Experiences and Development of Atypical Sensory Processing.

Importance: Atypical sensory processing is challenging for children and families, yet there is limited understanding of its associated risk factors. Objective: To determine the association between early-life digital media exposure and sensory processing outcomes among toddlers. Design, Setting, and Participants: This multicenter US study used data that were analyzed from the National Children's Study (NCS), a cohort study of environmental influences on child health and development, with enrollment from 2011 to 2014. Data analysis was performed in 2023. The study included children enrolled in the NCS at birth whose caregivers completed reports of digital media exposure and sensory processing. Exposures: Children's viewing of television or video at 12 months (yes or no), 18 months, and 24 months of age (hours per day). Main Outcomes and measures: Sensory processing was reported at approximately 33 months of age on the Infant/Toddler Sensory Profile. Quadrant scores (low registration, sensation seeking, sensory sensitivity, and sensation avoiding) were categorized into groups representing typical, high, and low sensory-related behaviors, and multinomial regression analyses were performed. Results: A total of 1471 children (50% male) were included. Screen exposure at 12 months of age was associated with a 2-fold increased odds of being in the high category of low registration (odds ratio [OR], 2.05; 95% CI, 1.31-3.20), while the odds of being in the low category instead of the typical category decreased for sensation seeking (OR, 0.55; 95% CI, 0.35-0.87), sensation avoiding (OR, 0.69; 95% CI, 0.50-0.94), and low registration (OR, 0.64; 95% CI, 0.44-0.92). At 18 months of age, greater screen exposure was associated with increased risk of high sensation avoiding (OR, 1.23; 95% CI, 1.03-1.46) and low registration (OR, 1.23; 95% CI, 1.04-1.44). At 24 months of age, greater screen exposure was associated with increased risk of high sensation seeking (OR, 1.20; 95% CI, 1.02-1.42), sensory sensitivity (OR, 1.25; 95% CI, 1.05-1.49), and sensation avoiding (OR, 1.21; 95% CI, 1.03-1.42). Conclusions and Relevance: In this cohort study, early-life digital media exposure was associated with atypical sensory processing outcomes in multiple domains. These findings suggest that digital media exposure might be a potential risk factor for the development of atypical sensory profiles. Further research is needed to understand the relationship between screen time and specific sensory-related developmental and behavioral outcomes, and whether minimizing early-life exposure can improve subsequent sensory-related outcomes.

Comorbidity profiles of patients experiencing homelessness: A latent class analysis.

Individuals experiencing homelessness are known to have increased rates of healthcare utilization when compared to the average patient population, often attributed to their complex health care needs and under or untreated comorbid conditions. With increasing focus on hospital readmissions among acute care settings, a better understanding of these comorbidity patterns and their impacts on acute care utilization could help improve quality of care. This study aims to identify distinct comorbidity profiles of homeless patients, and to explore the correlates of the identified comorbidity profiles and their impact on hospital readmission. This is a retrospective analysis using electronic health records (EHR) of patients experiencing homelessness encountered in the hospitals of ChristianaCare from 2015 to 2019 (N = 3445). Latent class analysis (LCA) was used to identify the comorbidity profiles of homeless patients. The mean age of the study population was 44-year, and the majority were male (63%). The most prevalent comorbid conditions were tobacco use (77%), followed by depression (58%), drug use disorder (56%), anxiety disorder (50%), hypertension (44%), and alcohol use disorder (43%). The LCA model identified 4 comorbidity classes-"relatively healthy" class with 31% of the patients, "medically-comorbid with SUD" class with 15% of the patients, "substance use disorder (SUD)" class with 39%, and "Medically comorbid" class with 15% of the patients. The Kaplan-Meir curves of probability of readmission against time from the index visits were significantly different for the four classes (p<0.001). The multivariable Cox proportional hazard model adjusted for age, sex, race, ethnicity, and insurance type showed that the hazard for readmission among patients in medically comorbid with SUD class is 3.16 (CI: 2.72, 3.67) times higher than the patients in the relatively healthy class.

Factors Associated With Hospital Readmission Among Patients Experiencing Homelessness.

INTRODUCTION: Homelessness is associated with increased acute care utilization and poor healthcare outcomes. This study aims to compare hospital readmission rates among patients experiencing homelessness and patients who are not homeless and assess the impact of different clinical and demographic characteristics on acute care utilization among patients experiencing homelessness. METHODS: This was a retrospective study of patients encountered in 2018 and 2019 at ChristianaCare Health Systems. The analysis was done in August 2021. The prevalence of major chronic conditions among patients experiencing homelessness (n=1,329) and those not experiencing it (n=143,360) was evaluated. Patients experiencing homelessness were matched with nonhomeless patients using 1:1 propensity score matching. Time-to-event analysis approaches were used to analyze time-to-readmission and 30-day readmission rates. RESULTS: The 30-day readmission rates were 42.8% among patients experiencing homelessness and 19.9% among matched patients not experiencing homelessness. The hazard of 30-day readmission among patients experiencing homelessness was 2.6 (95% CI=1.93, 3.53) times higher than that among the matched nonhomeless cohort. In patients experiencing homelessness, drug use disorder, major depressive disorder, chronic kidney disease, obesity, arthritis, HIV/AIDS, and epilepsy were associated with shortened time to readmission. Moreover, Black racial identity was associated with shortened time to readmission. CONCLUSIONS: Patients experiencing homelessness had higher acute care utilization than those not experiencing homelessness. Black racial identity and several comorbidities were associated with increased acute care utilization among patients experiencing homelessness. Efforts to address upstream social determinants of health, destigmatization, and healthcare management accounting for the whole spectrum of clinical comorbidities might be important in promoting the health of people experiencing homelessness.

Association between COVID-19 pandemic and the suicide rates in Nepal.

BACKGROUND: Past works have linked the COVID-19 pandemic and subsequent public health responses such as isolation, quarantine, and lockdown to increased anxiety, sleep disorders, depressive symptoms, and suicidal ideation. Only a few studies, mostly carried out in high-income countries, have investigated the association between the pandemic and suicide rate. We seek to investigate the changes in the monthly suicide rates during the COVID-19 pandemic in Nepal, compared to the pre-pandemic suicide rates. METHODS AND FINDINGS: This is a retrospective study investigating the changes in suicide rates in Nepal during the COVID-19 pandemic period (April 2020 to June 2021), compared to the pre-pandemic period (July 2017 to March 2020), adjusted for seasonality and long-term trend in the suicide rate. We performed analysis for the entire country as well as sub-sample analyses stratified by gender and provinces. A total of 24350 suicides deaths during four years of the study window were analyzed. We found an overall increase in the monthly suicide rate in Nepal with an average increase of 0.28 (CI: 0.12,0.45) suicide per 100,000 during the pandemic months. The increase in suicide rate was significant both among males (increase in rate = 0.26, CI: 0.02,0.50) and females (increase in rate = 0.30, CI: 0.18,0.43). The most striking increments in suicide rates were observed in June, July, and August 2020. The pattern of increased suicide rates faded away early on among males, but the effect was sustained for a longer duration among females. Sudurpaschim and Karnali provinces had the highest increase in suicide rates associated with the COVID-19 pandemic. CONCLUSIONS: The COVID-19 pandemic is associated with an increased suicide rate in Nepal. The findings may inform policymakers in designing appropriate public health responses to the pandemic that are considerate of the potential impact on mental health and suicide.

Escalation of Opioid Withdrawal Frequency and Subsequent AMA Rates in Hospitalized Patients From 2017 to 2020.

OBJECTIVE: To measure trends for the emergence of opioid withdrawal (OW) and leaving against medical advice (AMA) among hospitalized patients. METHOD: Retrospective time-series of hospitalized patients with OW, defined by a Clinical Opioid Withdrawal score >8, using electronic health record data at a tertiary health system and of patients with a discharge status of AMA from January 1, 2017 to December 31, 2020. RESULTS: The average number of monthly hospitalizations with OW showed a year-to-year increment of 15% in 2018, 21% in 2019, and 34% from 2019 to 2020, whereas the total monthly hospitalizations remained stable. The segmented regression analysis showed that the upward trend in hospitalizations with OW became significant after January 2019 (slope: 1.14, 95% confidence interval [CI]: 0.70, 1.57). After August 2019, Fentanyl was added to the hospital urine drug testing panel and was identified in most OW patients. The monthly proportion of patients who left AMA was significantly higher among the OW patients than among all other admitted patients. There was a significant increase of 0.39 (95% CI: 0.29-0.49, P < 0.001) per month in %AMA among patients with OW. The estimated difference in %AMA among OW patients versus all other patients was 7.25 (95% CI: 5.12-9.38) in January 2017, and 16.92 (95% CI: 14.60-19.24) in December 2020. CONCLUSIONS: The number of hospitalized patients either presenting with or developing OW increased between 2017 and 2020 with a significant rise occurring after January 2019. The percentage of patients who left AMA among those who developed OW steadily worsened during the entire study period.

Analysis of Factors Associated With Length of Stay of Opioid-Related Emergency Department Visits.

INTRODUCTION AND OBJECTIVE:  Emergency department (ED) length of stay (LOS) is an important indicator of the quality of care in ED and is associated with patients' outcomes and healthcare costs. However, there is limited data on how the patient characteristics affect the ED LOS of opioid-related visits. This study aims to identify and quantify the effect of patient-related characteristics on LOS of opioid-related ED visits. METHODS:  This is a retrospective analysis of electronic health records (EHR) of patients with diagnoses of opioid abuse. The study included patients with a diagnosis of opioid abuse who visited the ED at Christiana Care Hospital from January 1, 2017, to December 31, 2018 (N=5,661). The opioid-related visits were identified using ICD-10 diagnosis codes. We used accelerated failure time (AFT) models, a time-to-event analysis approach to evaluate the relationships of different patient characteristics with ED LOS. RESULTS:  The mean age of the study population was 39 years. The study population had 40% female, 20% Black/African American, and 5% Hispanic or Latino. The prevalence of co-use of cocaine and co-use of alcohol was 11%, and 9%, respectively. Also, 58% had mental health comorbidity, and 1% were homeless. The distribution of ED LOS was right-skewed with a median of 4.3 (IQR: 2.6, 6.8). Co-use of alcohol (time ratio, TR: 1.31, CI: 1.23-1.40), co-use of cocaine (TR: 1.18, CI: 1.11-1.25), the presence of mental health comorbidity (TR: 1.05, CI 1.01-1.09), and homelessness (TR: 1.57, CI: 1.32-1.86) were associated with increased ED LOS. CONCLUSIONS: Co-use of alcohol, co-use of cocaine, homelessness, and mental health comorbidity are associated with the longer LOS of opioid-related ED visits.

Characteristics and Outcomes of SARS-CoV-2 Infection Among Adults Living With HIV In Delaware:: The Story of a Syndemic During the First 12 Months of the SARS-CoV-2 Pandemic.

Objective: To better characterize the intersection of the HIV and SARS-CoV-2 pandemics, including our robust statewide panel of people living with HIV, in the State of Delaware. Methods: We conducted a retrospective descriptive case-series that identified people living with HIV ≥ 18 years old co-infected with SARS-CoV-2 from 1 March 2020 through 9 March 2021 who attended our ambulatory HIV program, through review of testing results, electronic medical records and external clinical records. Results: There were 105 confirmed cases of SARS-CoV-2 infection and 4 attributable deaths from COVID-19 among adult people living with HIV from 1 March 2020 through 9 March 2021. Co-infected patients had very high rates of ART prescription and virologic suppression, with robust CD4 counts. 24/105 (22.9%) SARS-CoV-2 cases were hospitalized due to COVID-19 and had a significant burden of co-morbidities; a vast majority were AIDS-defined. Age, BMI >30 kg/m2, cardiovascular disease, chronic kidney disease and cirrhosis were independently associated with hospitalization by logistic regression. Black patients appeared to have lower rates of testing and higher rates of hospitalization. Additionally, those with history of natural immunity to hepatitis B virus exhibited a low rate of hospitalization. Conclusions: Our cohort data is the first to capture the experience of patients co-infected with HIV/SARS-CoV-2 in Delaware, demonstrating the risk of long-term immunosuppression and burden of comorbid disease, even in the setting of virologic suppression. Although not reaching statistical significance, we identified high rates of resolved hepatitis B virus infection amongst non-hospitalized co-infected patients and postulate there may be an underlying immunologic mechanism to this hypothesis-generating observation. Our results also highlight the role that healthcare disparities have played during these overlapping pandemics. Policy Implications: Pronounced healthcare disparities are known to worsen outcomes in a variety of disease states. From our descriptive data, we suggest continued efforts to address the social determinants of health, especially as they pertain to common chronic comorbid conditions and certain Black communities.

Hospital length of stay among COVID-19-positive patients.

BACKGROUND AND AIM: This study aims to determine COVID-19 patient demographics and comorbidities associated with their hospital length of stay (LOS). METHODS: Design: Single-site, retrospective study. Setting: A suburban 700-bed community hospital in Newark, Delaware, USA. Patients: Patients admitted to the hospital from March 11, 2020, to August 11, 2020, with a positive COVID-19 status. We followed a time-to-event analysis approach and used Kaplan-Meir curves and log-rank tests for bivariate analyses, and an accelerated failure time model for a multivariable model of hospital LOS. RESULTS: Six hundred and eighty-seven patients discharged alive (mean [SD] age, 60.94 [18.10] years; 339 men [49.34%]; 307 Black/African-American [44.69%]; and 267 White [38.86%]) were included in the investigation. Bivariate analysis using Kaplan-Meir curves showed that patients' age, sex, ethnicity, insurance type, comorbidity of fluid and electrolyte disorder, hypertension, renal failure, diabetes, coagulopathy, congestive heart failure, peripheral vascular disease, neurological disorder, coronary artery disease, and cardiac arrhythmias to be significantly associated with LOS (P<0.05). In the multivariable analysis, patients' age, sex, ethnicity, number of Elixhauser comorbidities, and number of weeks since onset of the pandemic was significantly associated with LOS (P<0.05). Fluid and electrolyte disorder is the only comorbidity independently associated with LOS after adjusting for patients' age, sex, race, ethnicity, number of Elixhauser comorbidities, and weeks since onset of pandemic. CONCLUSION: COVID-19 patients LOS vary based on multiple factors. Understanding these factors are crucial to improving the prediction accuracy of COVID-19 patient census in hospitals for resource planning and care delivery. RELEVANCE FOR PATIENTS: Understanding of the factors associated with LOS of the COVID-19 patients may help the care providers and the patients to better anticipate the LOS, optimize the resources and processes, and prevent protracted stays.

Outcomes With Early Cardiac Catheterization in Out of Hospital Cardiac Arrest Survivors and Utility of a Prognostic Scoring System.

Objectives A retrospective study in patients presenting out of hospital cardiac arrest (OHCA) to assess the impact of early cardiac catheterization on survival and cerebral performance category (CPC) on discharge. Background The role of early coronary angiography in OHCA patients remains controversial. The cardiac arrest hospital prognosis (CAHP) scoring system has not been validated in the US population. Methods Inclusion criteria were OHCA patients with a sustained return of spontaneous circulation (ROSC), presumed cardiac cause of arrest, and elements to calculate CAHP score. We compared in-hospital mortality rates and final inpatient CPC in patients who underwent early cardiac catheterization to those with delayed or no cardiac catheterization. We assessed the performance of the CAHP score in the entire OHCA population using receiver-operator curve (ROC) analysis. Results A hundred and fifty-eight patients were included, of which 39 underwent early cardiac catheterization. The mortality rate of the early catheterization group was lower than the delayed or no catheterization group (41% vs 61.3%, p=0.02); the Early cardiac catheterization group had more favorable final hospital CPC scores overall (53.8% vs 24.3%, p<0.001). However, when risk-adjusted, there was no benefit in early catheterization for mortality or CPC level in any of the CAHP score subgroups. CAHP scores showed good discrimination with c-statistics of 0.85 for mortality and 0.90 for the CPC category. Conclusion Early use of cardiac catheterization in OHCA patients with sustained ROSC was not associated with lower mortality rates or higher rates of favorable neurologic recovery when adjusted for baseline risk factors in each of the different CAHP score-based sub-groups. This was despite a higher proportion of patients with STEMI in the early catheterization group. We demonstrated a good fit between observed outcomes and outcomes predicted by the CAHP scoring system.

Adjustment of high flow nasal cannula rates using real-time work of breathing indices in premature infants with respiratory insufficiency.

OBJECTIVE: To assess the feasibility of real-time monitoring of work of breathing (WOB) indices and the impact of adjusting HFNC flow on breathing synchrony and oxygen stability in premature infants. STUDY DESIGN: A prospective, observational study of infants stable on HFNC. The flow adjusted per predetermined algorithm. Respiratory inductive plethysmography (RIP) noninvasively measured WOB. A high-resolution pulse oximeter collected oxygen saturation and heart rate data. Summary statistics and mixed linear models were used. RESULTS: Baseline data for 32 infants, final analysis of 21 infants. Eighty-one percent with abnormal WOB. Sixty-two percent demonstrated 20% improvement in WOB. For infants with gestational age <28 weeks, an incremental increase in HFNC flow rate decreased WOB (p < 0.001) and improved oxygen saturation and stability (p < 0.01). CONCLUSIONS: Premature infants do not receive optimal support on HFNC. The use of a real-time feedback system to adjust HFNC is feasible and improves WOB, oxygen saturation, and oxygen stability. This technology may improve the utility of HFNC in premature infants.

An examination of cardiovascular intensive care unit mortality based on admission day and time.

BACKGROUND: Recent interest in the 'weekend effect' has been expanded to cardiovascular intensive care units, yet the impact of off-hours admission on mortality and cardiovascular ICU (CICU) length of stay remains uncertain. OBJECTIVES: We examine the association between CICU admission day and time with mortality. Additionally, length-of-stay was also evaluated in relation to admission time. METHODS: A single-center, retrospective cohort study was conducted including 10,638 adult patients admitted to a CICU in a tertiary-care academic medical center from July 1, 2012 to June 30, 2019. ICU mortality and length-of-stay were assessed by admission day and time adjusting for comorbid conditions and other clinical variables. We used logistic regression models to evaluate the factors associated with mortality and a generalized linear model (GLM) with log link function and gamma distribution was used to evaluate the factors associated with ICU length of stay. RESULTS: Compared to weekday-day admissions, we observed an increased mortality for weekend-day for all admissions (6.5 vs 9.6%, Adjusted OR: 1.32 (1.03-1.72)), and for medical CICU admissions (7.6 vs 9.9%, Adjusted OR: 1.35 (1.02-1.79)). Additionally, compared to weekday-day, weekday-night admission was associated with 7% longer ICU length of stay in surgical ICU patients, 7% shorter length of stay in medical ICU patients. CONCLUSION: Admission to this open-model CICU during weekend hours (Saturday 08:00-Sunday 17:59) versus nights or weekdays is associated with increased mortality. ICU staffing care models should not significantly change based on the day of the week.

Association of Early-Life Social and Digital Media Experiences With Development of Autism Spectrum Disorder-Like Symptoms.

Importance: Despite growing evidence that parent-child interactions and time viewing digital media affect child development, these factors have rarely been studied in association with autism spectrum disorder (ASD) symptoms. Objective: To determine the association of experiential factors, including social activities and screen viewing in the first 18 months of life, perinatal factors, and demographic factors, with ASD-like symptoms and risk on the Modified Checklist for Autism in Toddlers (M-CHAT) at 2 years. Design, Setting, and Participants: Data for this cohort study were derived from the National Children's Study, a US multicenter epidemiological study of environmental influences on child health and development. A total of 2152 children were enrolled at birth from October 1, 2010, to October 31, 2012. Data were analyzed from December 1, 2017, to December 3, 2019. Exposures: Caregivers reported whether the child viewed television and/or videos (yes or no) at 12 months of age, hours of viewing at 18 months of age, time spent by the caregiver reading to the child (number of days per week compared with daily) at 12 months of age, and frequency of playing with the child (daily or less than daily) at 12 months of age. Prematurity, maternal age at birth, child sex, household income, race/ethnicity, and caregiver English-language status were included in analysis. Main Outcomes and Measures: Significant association of exposures with ASD risk by M-CHAT and/or ASD-like symptoms assessed by revised M-CHAT (M-CHAT-R) total score in multiple regression models. Results: Among the 2152 children included in the analysis (1099 boys [51.1%]), television and/or video viewing (yes or no) at 12 months of age was significantly associated with greater ASD-like symptoms at 2 years of age (change, 4.2%; 95% CI, 0.1%-8.3%) but not with ASD risk (risk prevalence rates, 8.3% vs 4.4%; adjusted odds ratio [AOR], 1.40; 95% CI, 0.86-2.29). Similarly, parent-child play daily compared with less than daily was significantly associated with fewer ASD-like symptoms at 2 years of age (change, -8.9%; 95% CI, -16.5% to -0.9%) but not with ASD risk (risk prevalence rates, 6.4% vs 14.0%; AOR, 0.58; 95% CI, 0.31-1.08). However, high screen viewing at 18 months of age was not significantly associated with ASD-like symptoms (change, 10.7%; 95% CI, -2.0% to 23.0%) or ASD risk by M-CHAT (AOR, 1.18; 95% CI, 0.56-2.49) at 2 years of age. Conclusions and Relevance: This cohort study found greater screen exposure and less caregiver-child play early in life to be associated with later ASD-like symptoms. Further research is needed to evaluate experiential factors for potential risk or protective effects in ASD.

Nephrology Fellows' and Program Directors' Perceptions of Hospital Rounds in the United States.

BACKGROUND AND OBJECTIVES: Hospital rounds are a traditional vehicle for patient-care delivery and experiential learning for trainees. We aimed to characterize practices and perceptions of rounds in United States nephrology training programs. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS: We conducted a national survey of United States nephrology fellows and program directors. Fellows received the survey after completing the 2019 National Board of Medical Examiners Nephrology In-Training Exam. Program directors received the survey at the American Society of Nephrology's 2019 Nephrology Training Program Directors' Retreat. Surveys assessed the structure and perceptions of rounds, focusing on workload, workflow, value for patient care, and fellows' clinical skill-building. Directors were queried about their expectations for fellow prerounds and efficiency of rounds. Responses were quantified by proportions. RESULTS: Fellow and program director response rates were 73% (n=621) and 70% (n=55). Most fellows (74%) report a patient census of >15, arrive at the hospital before 7:00 am (59%), and complete progress notes after 5:00 pm (46%). Among several rounding activities, fellows most valued bedside discussions for building their clinical skills (34%), but only 30% examine all patients with the attending at the bedside. Most directors (71%) expect fellows to both examine patients and collect data before attending-rounds. A majority (78%) of directors commonly complete their documentation after 5:00 pm, and for 36%, after 8:00 pm. Like fellows, directors most value bedside discussion for development of fellows' clinical skills (44%). Lack of preparedness for the rigors of nephrology fellowship was the most-cited barrier to efficient rounds (31%). CONCLUSIONS: Hospital rounds in United States nephrology training programs are characterized by high patient volumes, early-morning starts, and late-evening clinical documentation. Fellows use a variety of prerounding styles and examine patients at the beside with their attendings at different frequencies. PODCAST: This article contains a podcast at https://www.asn-online.org/media/podcast/CJASN/2020_03_17_CJN.10190819.mp3.