Core requirements of frailty screening in the emergency department: an international Delphi consensus study.

INTRODUCTION: Frailty is associated with adverse outcomes among patients attending emergency departments (EDs). While multiple frailty screens are available, little is known about which variables are important to incorporate and how best to facilitate accurate, yet prompt ED screening. To understand the core requirements of frailty screening in ED, we conducted an international, modified, electronic two-round Delphi consensus study. METHODS: A two-round electronic Delphi involving 37 participants from 10 countries was undertaken. Statements were generated from a prior systematic review examining frailty screening instruments in ED (logistic, psychometric and clinimetric properties). Reflexive thematic analysis generated a list of 56 statements for Round 1 (August-September 2021). Four main themes identified were: (i) principles of frailty screening, (ii) practicalities and logistics, (iii) frailty domains and (iv) frailty risk factors. RESULTS: In Round 1, 13/56 statements (23%) were accepted. Following feedback, 22 new statements were created and 35 were re-circulated in Round 2 (October 2021). Of these, 19 (54%) were finally accepted. It was agreed that ideal frailty screens should be short (<5 min), multidimensional and well-calibrated across the spectrum of frailty, reflecting baseline status 2-4 weeks before presentation. Screening should ideally be routine, prompt (<4 h after arrival) and completed at first contact in ED. Functional ability, mobility, cognition, medication use and social factors were identified as the most important variables to include. CONCLUSIONS: Although a clear consensus was reached on important requirements of frailty screening in ED, and variables to include in an ideal screen, more research is required to operationalise screening in clinical practice.

Impact of a short-term low calorie diet alone or with interval exercise on quality of life and oxidized phospholipids in obese females.

The objective of this study was to test if a low-calorie diet plus interval exercise (LCD+INT) reduced oxidized and non-oxidized phospholipids in relation to improved weight-related quality of life (QoL) to a greater extent than an energy-deficit matched LCD in obese females. Subjects (age: 47.2 ± 2.6 years, body mass index: 37.5 ± 1.3 kg/m2) were randomized to a 13-day LCD (n = 12; mixed meals of ∼1200 kcal/day) or LCD+INT (n = 13; 12 sessions of 60 min/day alternating 3 min at 50% and 90% peak heart rate plus an additional 350 kcal shake fed after exercise to match energy availability between groups). Weight-related QoL (Laval Questionnaire) as well as oxidized (POVPC, HOOA-PC, HPETE-PC, HETE-PC, PEIPC, KOOA-PC) and non-oxidized (PAPC and lysoPC) phospholipids were assessed pre- and post-intervention. Fitness (VO2peak), body composition (BodPod), and clinical bloods were also tested. LCD+INT significantly increased VO2peak (mL/kg/min, P = 0.03) compared to LCD despite similar fat loss, blood glucose, insulin sensitivity, and inflammatory responses. LCD+INT had significantly greater increases in QoL sexual life domain (P = 0.05) and tended to have a greater increase in the emotions domain (P = 0.09) and total score (P = 0.10) compared to LCD. There were no significant differences between treatments for changes in phospholipids despite LCD+INT increasing measured oxidized and non-oxidized phospholipids while LCD decreased POVPC, HOOA-PC, and PEIPC as well as non-oxidized PAPC and lysoPC. Interestingly, the rise in PEIPC correlated with elevated VO2peak (mL/kg/min r = 0.42, P = 0.05). Decreased caloric intake was, however, linked to a decrease in PAPC (r = 0.53, P = 0.01), lysoPC (r = 0.52, P = 0.02), POVPC (r = 0.43, P = 0.05), and HPETE-PC (r = 0.43, P = 0.05). The decrease in HETE-PC also correlated with increases in the QoL domains symptoms (r = -0.46, P = 0.04), hygiene/clothing (r = -0.53, P = 0.01), emotions (r = -0.53, P = 0.01), social interactions (r = -0.49, P = 0.02), and total score (r = -0.52, P = 0.02). In conclusion, although LCD and LCD+INT improved weight related QoL over 13 days in females with obesity, LCD+INT tended to improve sexual life, emotions as well as total QoL score more than LCD. These data suggest caloric restriction and fitness may act through different mechanisms to support QoL.

Electronic Glycemic Management System and Endocrinology Service Improve Value in Cardiac Surgery.

BACKGROUND: Postoperative glycemic control improves cardiac surgery outcomes but insulin protocols are limited by complexity and inflexibility. We sought to evaluate the effect of implementing an electronic glycemic management system (eGMS) in conjunction with a cardiac surgery endocrinology consult service on glycemic control and outcomes after cardiac surgery. METHODS: All patients with a calculated preoperative risk of mortality who underwent cardiac surgery before and after implementation of an eGMS and an endocrinology consult service were identified. Glycemic control and surgical outcomes were compared using univariate analysis, and multivariate regression was used to model the risk-adjusted effects of the interventions on glycemic control, surgical outcomes, and resource utilization. The health care-related value added by the interventions was calculated by dividing risk-adjusted outcomes by total hospital costs. RESULTS: A total of 2612 patients were identified, with 1263 patients in the preimplementation cohort and 1349 in the postimplementation cohort. Multivariate regression demonstrated fewer postoperative hyperglycemic events (odds ratio [OR] 0.8, 95% CI, 0.65-0.99) after protocol implementation without an increase in hypoglycemic events (OR 0.96, 95% CI, 0.71-1.3). Average day-weighted mean glucose decreased from 144 to 138 mg/dL (P < .001). The improved glycemic control correlated with a risk-adjusted decrease in composite morbidity or mortality (OR 0.61, 95% CI, 0.47-0.79). Although hospital costs increased after implementation, the protocol increased health care-related value by 38%. CONCLUSION: Implementation of a protocol consisting of an eGMS paired with a cardiac surgery-specific endocrinology consult service was associated with improved glycemic control and reduced morbidity. Despite higher costs health care-related value increased as a result of eGMS implementation.

A MULTICENTER STUDY EVALUATING PERCEPTIONS AND KNOWLEDGE OF INPATIENT GLYCEMIC CONTROL AMONG RESIDENT PHYSICIANS: ANALYZING THEMES TO INFORM AND IMPROVE CARE.

Objective: In this descriptive study, we evaluated perceptions and knowledge of inpatient glycemic control among resident physicians. Methods: We performed this study at four academic medical centers: the University of Mississippi Medical Center, University of Virginia Health System, University of Louisville Health Sciences Center, and Emory University. We designed a questionnaire, and Institutional Review Board approval was granted at each institution prior to study initiation. We then administered the questionnaire to Internal Medicine and Medicine-Pediatric resident physicians. Results: A total of 246 of 438 (56.2%) eligible resident physicians completed the Inpatient Glycemic Control Questionnaire (IGCQ). Most respondents (85.4%) reported feeling comfortable treating and managing inpatient hyperglycemia, and a majority (66.3%) agreed they had received adequate education. Despite self-reported comfort with knowledge, only 51.2% of respondents could identify appropriate glycemic targets in critically ill patients. Only 45.5% correctly identified appropriate inpatient random glycemic target values in noncritically ill patients, and only 34.1% of respondents knew appropriate preprandial glycemic targets in noncritically ill patients. A small majority (54.1%) were able to identify the correct fingerstick glucose value that defines hypoglycemia. System issues were the most commonly cited barrier to successful inpatient glycemic control. Conclusion: Most respondents reported feeling comfortable managing inpatient hyperglycemia but had difficulty identifying appropriate inpatient glycemic target values. Future interventions could utilize the IGCQ as a pre- and postassessment tool and focus on early resident education along with improving system environments to aid in successful inpatient glycemic control. Abbreviations: DM = diabetes mellitus; Emory = Emory University Healthcare; IGC = inpatient glycemic control; IGCQ = Inpatient Glycemic Control Questionnaire; IRB = Institutional Review Board; PGY = postgraduate year; UMMC = University of Mississippi Medical Center; UVA = University of Virginia Health System; UL = University of Louisville Health Sciences Center.

Construction and preliminary evaluation of the inpatient glycemic control questionnaire (IGCQ): a survey tool assessing perceptions and knowledge of resident physicians.

BACKGROUND: Uncontrolled hyperglycemia in hospitalized patients, with or without diabetes mellitus, is associated with many adverse outcomes. Resident physicians are the primary managers of inpatient glycemic control (IGC) in many academic and community medical centers; however, no validated survey tools related to their perceptions and knowledge of IGC are currently available. As identification of common barriers to successful IGC amongst resident physicians may help foster better educational interventions (ultimately leading to improvements in IGC and patient care), we sought to construct and preliminarily evaluate such a survey tool. METHODS: We developed the IGC questionnaire (IGCQ) by using previously published but unvalidated survey tools related to physician perspectives on inpatient glycemic control as a framework. We administered the IGCQ to a cohort of resident physicians from the University of Mississippi Medical Center, University of Louisville, Emory University, and the University of Virginia. We then used classical test theory and Rasch Partial Credit Model analyses to preliminarily evaluate and revise the IGCQ. The final survey tool contains 16 total items and three answer-choice categories for most items. RESULTS: Two hundred forty-six of 438 (56.2%) eligible resident physicians completed the IGCQ during various phases of development. CONCLUSIONS: We constructed and preliminarily evaluated the IGCQ, a survey tool that may be useful for future research into resident physician perceptions and knowledge of IGC. Future studies could seek to externally validate the IGCQ and then utilize the survey tool in pre- and post-intervention assessments.

Bariatric surgery reduces incidence of atrial fibrillation: a propensity score-matched analysis.

BACKGROUND: Obesity is associated with an increased risk of atrial fibrillation (AF). Bariatric surgery results insubstantial long-term weight loss and the amelioration of several chronic comorbidities. We hypothesized that weightreduction with bariatric surgery would reduce the long-term incidence of AF. OBJECTIVES: To assess the association between bariatric surgery and AF prevention. SETTING: University Hospital, United States. METHODS: All patients who underwent bariatric surgery at a single institution from 1985-2015 (n = 3,572) were propensity score matched 1:1 to a control population of obese patients with outpatient appointments (n = 45,750) in our clinical data repository. Patients with a prior diagnosis of AF were excluded. Demographics, relevant comorbidities, and insurance status were collected and a chart review was performed for all patients with AF. Paired univariate analyses were used to compare the two groups. RESULTS: After propensity score matching, 5,044 total patients were included (2,522 surgical, 2,522 non-surgical). There were no differences in preoperative body mass index (BMI) (47.1 vs 47.7 kg/m2, P = 0.76) or medical comorbidities between groups. The incidence of AF was lower among surgical patients (0.8% vs 2.9%, P = 0.0001). In patients ultimately diagnosed with AF, time from enrollment to development of AF did not differ between groups; however, surgical patients with AF experienced a significantly higher reduction in excess BMI compared to non-surgical patients with AF (57.9% vs -3.8%, P<0.001). CONCLUSION: The incidence of AF was lower among patients who underwent bariatric surgery compared to their medically managed counterparts. Weight reduction with bariatric surgery may reduce the long-term incidence of AF.

The Association between Symptom Accommodation and Emotional Coregulation in Couples with Binge Eating Disorder.

Intense negative emotions and maladaptive behavioral strategies to reduce emotional distress occur not only in patients with various forms of psychopathology but also in their committed partners. One common strategy to reduce distress is for partners to accommodate to the symptoms of the disorder, which reduces distress short term but maintains symptoms long term. Accommodation is believed to be motivated by the partner reacting behaviorally to the patient's emotions, but the emotions of the partner in this context have yet to be examined. This pilot study examined how partner accommodation related to specific patterns of emotional coregulation between patients with binge eating disorder (BED) and their partners, before and after a couple-based intervention for BED. Vocally encoded emotional arousal was measured during couples' (n = 11) conversations about BED. As predicted, partners' emotional reactivity to patients' emotional arousal was associated with high accommodation before treatment. Thus, partners may use accommodation as a strategy to reduce both the patients' and their own distress. After treatment, partners' arousal was no longer associated with the patients' emotional arousal; instead, partners showed greater emotional stability over time, specifically when accommodation was low. Additionally, patients were less emotionally aroused after treatment. Therefore, treatment may have decreased overall emotionality of patients and altered the association between accommodation and partners' emotional reactivity. If replicated, this understanding of the emotional context associated with accommodation in BED can inform couple-based treatment by targeting specific emotional precipitants of behaviors that maintain symptoms.

La emociones negativas intensas y las estrategias conductuales desadaptativas para reducir el distrés emocional se producen no solo en pacientes con varias formas de psicopatología, sino también en sus parejas estables. Una estrategia común para disminuir el distrés es que las parejas se adapten a los síntomas del trastorno, lo cual reduce el distrés a corto plazo pero mantiene los síntomas a largo plazo. Se cree que la adaptación está motivada por la reacción conductual de la pareja a las emociones del paciente, pero las emociones de la pareja en este contexto aún no se han analizado. Este estudio piloto examinó cómo la adaptación de la pareja está relacionada con patrones específicos de corregulación emocional entre los pacientes con trastorno por atracón de alimentos y sus parejas, antes y después de una intervención en la pareja por trastorno por atracón de alimentos. Se midió la excitación emocional codificada en la voz durante conversaciones de las parejas (n = 11) acerca del trastorno por atracón de alimentos. Como se anticipó, la reacción emocional de las parejas a la excitación emocional de los pacientes estuvo asociada con una alta adaptación antes del tratamiento. Por lo tanto, las parejas pueden usar la adaptación como estrategia para reducir tanto el distrés de los pacientes como el propio. Después del tratamiento, la excitación de las parejas dejó de estar asociada con la excitación emocional de los pacientes. En cambio, las parejas demostraron una mayor estabilidad emocional con el tiempo, específicamente cuando la adaptación fue baja. Además, los pacientes estuvieron menos excitados emocionalmente después del tratamiento. En consecuencia, el tratamiento pudo haber disminuido la emocionalidad general de los pacientes y modificado la asociación entre la adaptación y la reacción emocional de las parejas. Si se reproduce, esta comprensión del contexto emocional asociada con la adaptación en los trastornos por atracón de alimentos puede fundamentar el tratamiento basado en la pareja abordando precipitantes emocionales específicos de conductas que mantienen los síntomas.

A pilot open trial of UNITE-BED: A couple-based intervention for binge-eating disorder.

OBJECTIVE: To evaluate the feasibility, acceptability, and preliminary efficacy of a couple-based intervention for binge-eating disorder (BED), called UNiting couples In the Treatment of Eating disorders-BED edition (UNITE-BED). METHOD: In an open pilot trial, 11 couples in which one or both adult partners had a diagnosis of DSM-5 threshold or sub-threshold BED participated in 22 weekly sessions of UNITE-BED. Patients also received individual treatment, outside of the context of the trial. Couples completed measures on treatment satisfaction, eating disorder symptom severity, depression, anxiety, emotion regulation, and relational functioning at post-treatment and 3-month follow-up. Statistical analyses were conducted to identify change over the course of treatment. RESULTS: UNITE was feasible and acceptable to the majority of couples (9% dropout; high satisfaction ratings). Objective binge abstinence was 81.8% and subjective binge abstinence was 45.5% by post-treatment. Patient binge-eating symptomatology reduced over the course of treatment with results maintained at follow up. Patients' depression symptoms decreased and patients' emotion regulation improved at both time points. DISCUSSION: Including partners in treatment for BED may be beneficial. Results support further evaluation of the efficacy of couple-based interventions for BED in larger randomized-controlled trials.

Bariatric Surgery Resistance: Using Preoperative Lifestyle Medicine and/or Pharmacology for Metabolic Responsiveness.

Bariatric surgery is an effective and durable treatment for individuals with obesity and its associated comorbidities. However, not all patients meet weight loss and/or cardiometabolic goals following bariatric surgery, suggesting that some people are bariatric surgery resistant. The reason for this resistance is unclear, but potential factors, such as adiposity-derived inflammation, insulin resistance, hyperglycemia, and aerobic fitness prior to surgery, have been related to blunted surgery responsiveness. Exercise, diet, and/or pharmacology are effective at reducing inflammation and improving insulin action as well as physical function. Herein, we present data that supports the novel hypothesis that intervening prior to surgery can enhance disease resolution in people who are resistant to bariatric surgery.

Clinical significance of failure to lose weight 10 years after roux-en-y gastric bypass.

BACKGROUND: Although Roux-en-Y gastric bypass (RYGB) induces short-term weight loss and co-morbidity amelioration, long-term data suggest that a subset of patients return to their preoperative body mass index (BMI). OBJECTIVES: To identify the clinical implications of 10-year weight loss failure after RYGB. SETTING: An academic teaching hospital. METHODS: Adults undergoing RYGB (1985-2004) were included in this study (n = 1087). Absolute weight loss failure was defined as ≤0% reduction in excess BMI 10 years after surgery. Univariate analyses compared co-morbidity rates and resolution by weight loss classification. Multivariable regression modeling analyzed preoperative predictors of 10-year percent reduction in excess BMI and weight loss failure. RESULTS: Complete follow-up was available for 617 (57%) patients with a 10-year median percent reduction in excess BMI of 57.1%; 10.2% of patients had weight loss failure. Prevalence of all co-morbidities decreased, even in patients with weight loss failure (all P<.05). Compared with patients with successful weight loss, patients with weight loss failure had similar rates of resolution of pre-existing co-morbidities, except for reduced resolution of apnea and cardiac co-morbidities (both P<.05). Risk factors for weight loss failure included lower BMI, nongovernmental insurance, longer travel time to hospital, and year of surgery. Nongovernmental insurance (odds ratio 2.03, P = .036) conferred the highest adjusted odds of weight loss failure. CONCLUSIONS: The vast majority of patients experience dramatic health improvement 10 years after RYGB, even though some patients fail to maintain their weight loss. Renewed focus should be placed on prevention and treatment of chronic disease, with further investigation of weight loss independent mechanisms of health improvement.

Hypoglycemia Following Bariatric Surgery: Our 31-Year Experience.

PURPOSE: The purposes of this study are to identify the cumulative incidence of post-bariatric surgery hypoglycemia (PBSH), describe its symptomatology, and characterize treatment patterns at a large academic institution. MATERIALS AND METHODS: All patients who underwent bariatric surgery at a single institution from 1985 to 2015 were identified using a clinical database, administrative billing data identified patients who were treated for hypoglycemia, and chart reviews were performed to make a diagnosis of PBSH based on Whipple's triad. PBSH cases were reviewed including patient diabetes history, symptomatology, and treatment measures. Univariate analyses were performed to identify correlations based on symptomatology, laboratory values, and treatments utilized. RESULTS: Ninety (2.6%) of 3487 patients were diagnosed with PBSH with preoperative median age of 43 years, mean BMI of 50.0 kg/m2, and median glycated hemoglobin of 6.0%. Median time-to-first hypoglycemic event was 40.6 months. No factors were identified which predict symptom severity or resolution. The 24 (27%) patients who received pharmacotherapy to treat hypoglycemia were younger, had lower nadir blood glucose levels, and more frequent symptoms. Sixty-nine (79%) cases eventually resolved. CONCLUSIONS: PBSH onset and severity are highly variable. Successful management of these patients can prove difficult and should include dietary therapy, the selective use of pharmacotherapy and surgery, and the use of a multidisciplinary team including bariatric surgeons and endocrinologists.

Findings from a couple-based open trial for adult anorexia nervosa.

Adult anorexia nervosa (AN) often is persistent, significantly erodes quality of life for both the patient and loved ones, and carries high medical and psychiatric comorbidity. Whereas individual psychotherapy for adult AN leads to improvement in some patients, recent findings indicate that the magnitude of improvement is limited: Only a small percentage of individuals fully recover and dropout rates are high. Thus, it is important to build upon current interventions to improve treatment response. We present results from an open trial of a couple-based intervention for adult anorexia nervosa as an adjunct treatment to standard multidisciplinary care. Twenty couples received treatment over approximately 26 weeks, including a couple-based intervention, individual CBT sessions, psychiatry visits for medication management, and nutritional counseling sessions. The results indicate that patients improved at posttest and 3-month follow-up on a variety of AN-related measures, anxiety and depression, and relationship adjustment. Partners also improved on anxiety, depression, and relationship adjustment. In an exploratory analysis, the multicomponent couple treatment intervention was benchmarked to well-conducted randomized controlled trials of individual therapy for AN; the couple intervention seems to compare favorably on AN-related measures and was associated with a lower dropout rate. In spite of methodological limitations, the findings suggest that including partners in the treatment of adult AN holds potential for bolstering treatment outcomes. (PsycINFO Database Record

Bariatric surgery insurance requirements independently predict surgery dropout.

BACKGROUND: Many insurance companies have considerable prebariatric surgery requirements despite a lack of evidence for improved clinical outcomes. The hypothesis of this study is that insurance-specific requirements will be associated with a decreased progression to surgery and increased delay in time to surgery. METHODS: Retrospective data collection was performed for patients undergoing bariatric surgery evaluation from 2010-2015. Patients who underwent surgery (SGY; n = 827; mean body mass index [BMI] 49.1) were compared with those who did not (no-SGY; n = 648; mean BMI: 49.4). Univariate and multivariate analysis were performed to identify specific co-morbidity and insurance specific predictors of surgical dropout and time to surgery. RESULTS: A total of 1475 patients using 12 major insurance payors were included. Univariate analysis found insurance requirements associated with surgical drop out included longer median diet duration (no-SGY = 6 mo; SGY = 3 mo; P<.001); primary care physician letter of necessity (P<.0001); laboratory testing (P = .019); and evaluation by cardiology (P<.001), pulmonology (P<.0001), or psychiatry (P = .0003). Using logistic regression to control for co-morbidities, longer diet requirement (odds ratio [OR] .88, P<.0001), primary care physician letter (OR .33, P<.0001), cardiology evaluation (OR .22, P = .038), and advanced laboratory testing (OR 5.75, P = .019) independently predicted surgery dropout. Additionally, surgical patients had an average interval between initial visit and surgery of 5.8±4.6 months with significant weight gain (2.1 kg, P<.0001). CONCLUSION: Many prebariatric surgery insurance requirements were associated with lack of patient progression to surgery in this study. In addition, delays in surgery were associated with preoperative weight gain. Although prospective and multicenter studies are needed, these findings have major policy implications suggesting insurance requirements may need to be reconsidered to improve medical care.

Type 2 diabetes remission following gastric bypass: does diarem stand the test of time?

OBJECTIVE(S): Roux-en-Y Gastric Bypass (RYGB) is well known to ameliorate type 2 diabetes mellitus (T2DM), and recent work suggests that the preoperative DiaREM model predicts successful remission up to 1 year post-RYGB. However, no data exist for long-term validity. Therefore, we sought to determine the utility of this score on long-term RYGB effectiveness for T2DM resolution at 2 and 10 years, respectively. METHODS: T2DM patients (Age: 48, BMI: 49, HbA1C: 8.1) undergoing RYGB at the University of Virginia between 2004-2006 (n = 42) and 2012-2014 (n = 59) were evaluated prospectively to assess preoperative DiaREM score, defined from insulin use, age, HbA1C, and type of antidiabetic medication. T2DM partial remission status was based on the American Diabetes Association guidelines (HbA1C < 6.5 % and fasting glycemia <125 mg/dL, and no anti-diabetic medications). Chi-square test was used to compare patient's T2DM status to their DiaREM probability of remission. RESULTS: Among RYGB patients with 2-year postoperative data, 2 were lost (n = 1 no follow-up and n = 1 died) resulting in 57 patients for analysis. For the 10-year postoperative data, 11 were lost (n = 6 no follow-up and n = 5 died), thereby resulting in only 31 patients for analysis. Patients were distributed by DiaREM score to correlate with the predicted probability of remission as follows: 0-2 (Predicted 94 %, 2-year 100 % p = 0.61, 10-year 100 % p = 0.72), 3-7 (Predicted 76 %, 2-year 94 % p = 0.08, 10-year 83 % p = 0.57), 8-12 (Predicted 36 %, 2-year 47 % p = 0.38, 10-year 43 % p = 0.72), 13-17 (Predicted 22 %, 2-year 20 % p = 0.92, 10-year 33 % p = 0.64), and 18-22 (Predicted 9 %, 2-year 15 % p = 0.40, 10-year 14 % p = 0.64). CONCLUSIONS: Preoperative DiaREM scores are a good tool for predicting both short- and long-term T2DM remissions following RYGB. This study highlights the need to identify strategies that improve T2DM remission in those at highest risk.

Postoperative Hypoglycemia Is Associated With Worse Outcomes After Cardiac Operations.

BACKGROUND: Hypoglycemia is a known risk of intensive postoperative glucose control in patients undergoing cardiac operations. However, neither the consequences of hypoglycemia relative to hyperglycemia, nor the possible interaction effects, have been well described. We examined the effects of postoperative hypoglycemia, hyperglycemia, and their interaction on short-term morbidity and mortality. METHODS: Single-institution Society of Thoracic Surgeons (STS) database patient records from 2010 to 2014 were merged with clinical data, including blood glucose values measured in the intensive care unit (ICU). Exclusion criteria included fewer than three glucose measurements and absence of an STS predicted risk of morbidity or mortality score. Primary outcomes were operative mortality and composite major morbidity (permanent stroke, renal failure, prolonged ventilation, pneumonia, or myocardial infarction). Secondary outcomes included ICU and postoperative length of stay. Hypoglycemia was defined as below 70 mg/dL, and hyperglycemia as above 180 mg/dL. Simple and multivariable regression models were used to evaluate the outcomes. RESULTS: A total of 2,285 patient records met the selection criteria for analysis. The mean postoperative glucose level was 140.8 ± 18.8 mg/dL. Overall, 21.4% of patients experienced a hypoglycemic episode (n = 488), and 1.05% (n = 24) had a severe hypoglycemic episode (<40 mg/dL). The unadjusted odds ratio (UOR) for operative mortality for patients with any hypoglycemic episode compared with those without was 5.47 (95% confidence interval [CI] 3.14 to 9.54), and the UOR for major morbidity was 4.66 (95% CI 3.55 to 6.11). After adjustment for predicted risk of morbidity or mortality and other significant covariates, the adjusted odds (AOR) of operative mortality were significant for patients with any hypoglycemia (AOR 4.88, 95% CI 2.67 to 8.92) and patients with both events (AOR 8.29, 95% CI 1.83 to 37.5) but not hyperglycemia alone (AOR 1.62, 95% CI 0.56 to 4.69). The AOR of major morbidity for patients with both hypoglycemic and hyperglycemic events was 14.3 (95% CI 6.50 to 31.4). CONCLUSIONS: Postoperative hypoglycemia is associated with both mortality and major morbidity after cardiac operations. The combination of both hyperglycemia and hypoglycemia represents a substantial increase in risk. Although it remains unclear whether hypoglycemia is a cause, an early warning sign, or a result of adverse events, this study suggests that hypoglycemia may be an important event in the postoperative period after cardiac operations.

Disorder-specific patterns of emotion coregulation in couples: Comparing obsessive compulsive disorder and anorexia nervosa.

Impaired emotion regulation and maladaptive strategies to manage distress are central to psychopathology, including obsessive-compulsive disorder (OCD) and anorexia nervosa (AN). Emotion regulation can be fostered or thwarted by romantic partners, and the tendency to rely on interpersonally oriented emotion regulation may vary by disorder. This study examined coregulation as a form of interpersonal emotion regulation in OCD and AN. We hypothesized that OCD is associated with exaggerated and AN with diminished coregulation, and that OCD patients have greater overall levels of emotional arousal than AN patients. Greater symptom severity was expected to exacerbate these opposing tendencies. Vocally encoded emotional arousal was measured during couple conversations in 34 AN patients, 18 OCD patients, and their partners. Two indicators of coregulation (covariation and coupling) were analyzed using cross-lagged actor-partner interdependence and coupled linear oscillator models. As hypothesized, OCD was associated with greater overall emotional arousal than AN. Symptom severity was not associated with emotional arousal or coregulation. Covariation differed in the opposite direction of the hypothesis; there was no difference in coupling. AN patients exhibited consistent coregulation, indicating high reactivity to partners' emotional arousal which may contribute to interpersonal avoidance. OCD couples showed limited predictability of patients' arousal over time, while partners were affected by the patients' emotional arousal; thus, symptom accommodation may in part be partners' attempts at managing their own distress along with the patients'. A better understanding of interpersonal emotion regulation in OCD and AN can inform treatment by targeting interaction patterns that may maintain symptoms. (PsycINFO Database Record

Protocol for a feasibility study of a self-help cognitive behavioural therapy resource for the reduction of dental anxiety in young people.

BACKGROUND: Childhood dental anxiety is very common, with 10-20 % of children and young people reporting high levels of dental anxiety. It is distressing and has a negative impact on the quality of life of young people and their parents as well as being associated with poor oral health. Affected individuals may develop a lifelong reliance on general anaesthetic or sedation for necessary dental treatment thus requiring the support of specialist dental services. Children and young people with dental anxiety therefore require additional clinical time and can be costly to treat in the long term. The reduction of dental anxiety through the use of effective psychological techniques is, therefore, of high importance. However, there is a lack of high-quality research investigating the impact of cognitive behavioural therapy (CBT) approaches when applied to young people's dental anxiety. METHODS/DESIGN: The first part of the study will develop a profile of dentally anxious young people using a prospective questionnaire sent to a consecutive sample of 100 young people referred to the Paediatric Dentistry Department, Charles Clifford Dental Hospital, in Sheffield. The second part will involve interviewing a purposive sample of 15-20 dental team members on their perceptions of a CBT self-help resource for dental anxiety, their opinions on whether they might use such a resource with patients, and their willingness to recruit participants to a future randomised controlled trial (RCT) to evaluate the resource. The third part of the study will investigate the most appropriate outcome measures to include in a trial, the acceptability of the resource, and retention and completion rates of treatment with a sample of 60 dentally anxious young people using the CBT resource. DISCUSSION: This study will provide information on the profile of dentally anxious young people who could potentially be helped by a guided self-help CBT resource. It will gain the perceptions of dental care team members of guided self-help CBT for dental anxiety in young people and their willingness to recruit participants to a trial. Acceptability of the resource to participants and retention and completion rates will also be investigated to inform a future RCT.

Couple-based interventions in the treatment of adult anorexia nervosa: A brief case example of UCAN.

Adult anorexia nervosa (AN) is a serious and often fatal illness that significantly erodes quality of life for both the patient and loved ones. Treatment of adults with AN has focused largely on individual therapy, with recent findings suggesting that improvement is limited and dropout rates are high. In an effort to improve treatment response, we developed a couple-based intervention, Uniting Couples in the treatment of Anorexia Nervosa (UCAN) as an adjunct treatment to standard multidisciplinary care. UCAN leverages the support of a partner and the relationship in treatment by decreasing avoidance around AN, teaching the couple how to effectively address the eating disorder, and helping to foster a more satisfying relationship. This paper presents a case study of a couple who completed UCAN, "Laura and Steve," including their experiences in treatment and outcome measures at pretest, posttest, and 3-month follow-up. Laura showed clinically significant change on the Restraint subscale of the Eating Disorders Examination at follow-up, and both partners showed clinically significant improvements in relationship satisfaction, as well as on self-reported and observed communication. Both partners reported very high satisfaction with the treatment. A discussion of therapists' experiences in delivering UCAN is provided, including common challenges for therapists with primarily a couple therapy or an individual CBT for eating disorders background, as well as important factors for therapists to consider in order to optimally leverage the benefits of including partners in treatment for AN. (PsycINFO Database Record

Protective Role for B-1b B Cells and IgM in Obesity-Associated Inflammation, Glucose Intolerance, and Insulin Resistance.

OBJECTIVE: Little is known about the role(s) B cells play in obesity-induced metabolic dysfunction. This study used a mouse with B-cell-specific deletion of Id3 (Id3(Bcell KO)) to identify B-cell functions involved in the metabolic consequences of obesity. APPROACH AND RESULTS: Diet-induced obese Id3(Bcell KO) mice demonstrated attenuated inflammation and insulin resistance in visceral adipose tissue (VAT), and improved systemic glucose tolerance. VAT in Id3(Bcell KO) mice had increased B-1b B cells and elevated IgM natural antibodies to oxidation-specific epitopes. B-1b B cells reduced cytokine production in VAT M1 macrophages, and adoptively transferred B-1b B cells trafficked to VAT and produced natural antibodies for the duration of 13-week studies. B-1b B cells null for Id3 demonstrated increased proliferation, established larger populations in Rag1(-/-) VAT, and attenuated diet-induced glucose intolerance and VAT insulin resistance in Rag1(-/-) hosts. However, transfer of B-1b B cells unable to secrete IgM had no effect on glucose tolerance. In an obese human population, results provided the first evidence that B-1 cells are enriched in human VAT and IgM antibodies to oxidation-specific epitopes inversely correlated with inflammation and insulin resistance. CONCLUSIONS: NAb-producing B-1b B cells are increased in Id3(Bcell KO) mice and attenuate adipose tissue inflammation and glucose intolerance in diet-induced obese mice. Additional findings are the first to identify VAT as a reservoir for human B-1 cells and to link anti-inflammatory IgM antibodies with reduced inflammation and improved metabolic phenotype in obese humans.

Couple-Based Interventions for Adults With Eating Disorders.

A significant number of adults with eating disorders fail to achieve relief from the disorder, with many dropping out of treatment or relapsing. The standard treatment remains individual therapy despite partners being negatively affected and typically wanting to help in an effective and loving way. We propose that couple-based interventions, which leverage the support of a partner and the relationship in treatment, may improve outcome and recovery rates for adults with eating disorders. In this article, we survey the empirical literature supporting the treatment of adults in a couple context and describe our existing and emerging couple-based interventions for eating disorders.