Does the sound environment influence the behaviour of zoo-housed birds? A preliminary investigation of ten species across two zoos.

In the zoo, the sound environment experienced by captive wild animals will contain numerous anthropogenic features that may elicit different responses to those stimulated by naturally created, or more biologically relevant, sounds. Husbandry activities, visitor presence and neighbouring species (free-living and captive) will all influence the sounds around zoo-housed species; an animal's behavioural responses may therefore provide an insight into how its welfare state is influenced by this changing sound environment. This project aimed to investigate how animal behaviour was influenced by the sound environment at two large UK zoos; one situated in a more rural location and the other in an urban location. Species were selected based on their location in the zoo, the relevance of sound to their natural ecology (e.g., as a form of communication and/or for anti-predator responses) and their novelty as research subjects in the scientific literature. Behavioural data collection was conducted for five days per enclosure per zoo at the population and individual level for birds housed in different styles of enclosure. Instantaneous sampling at one-minute intervals was used to collect information on state behaviours, assessed using a pre-determined species-specific ethogram. Event behaviours were collected continuously for each observation period. The sound environment around or in the enclosure was recorded continuously during each behavioural recording session using a recorder mounted on a tripod. Results showed a variety of responses to the presence of visitors and potential associated changes to sound around the enclosure with some behaviours being more influenced by the presence of visitors (and increases in the volume of sound) compared to others, e.g., vigilance and vocalisations. Overall, birds showed few of the changes thought to indicate poor or impoverished welfare states linked to changes to the sound environment in their enclosure or to the presence of visitors, but we recommend that zoos consider further measurement and recording of sound on a species-by-species basis to capture individual responses and behavioural changes to variation in visitor number and the sound environment.

The Utilization of Critical Care Resources in Pediatric Neurocritical Care Patients.

OBJECTIVES: To define the prevalence of neurologic diagnoses and evaluate the utilization of critical care and neurocritical care (NCC) resources among children admitted to the PICU. DESIGN: Retrospective cohort analysis. SETTING: Data submitted to the Virtual Pediatric Systems (VPS) database. PATIENTS: All children entered in VPS during 2016 (January 1, 2016, to December 31, 2016). INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: There were 128,688 patients entered into VPS and were comprised of 24.3% NCC admissions and 75.7% general PICU admissions. The NCC cohort was older, represented more scheduled admissions, and was more frequently admitted from the operating room. The NCC cohort also experienced a greater decline in prehospitalization to posthospitalization functional status and required more frequent use of endotracheal intubation, arterial lines, and foley catheters but had an overall shorter duration of PICU and hospital length of stay with a higher mortality rate. One thousand seven hundred fifteen patients at 12 participating institutions were entered into a novel, pilot NCC module evaluating sources of secondary neurologic injury. Four hundred forty-eight patients were manually excluded by the data entrant, leaving 1,267 patients in the module. Of the patients in the module, 75.8% of patients had a NCC diagnosis as their primary diagnosis; they experienced a high prevalence of pathophysiologic events associated with secondary neurologic insult (ranging from hyperglycemia at 10.5% to hyperthermia at 36.8%). CONCLUSIONS: In children admitted to a VPS-contributing PICU, a diagnosis of acute neurologic disease was associated with greater use of resources. We have identified the most common etiologies of acute neurologic disease in the 2016 VPS cohort, and such admissions were associated with significant decrease in functional status, as well as an increase in mortality.

Genomic analysis of Leuconostoc citreum TR116 with metabolic reconstruction and the effects of fructose on gene expression for mannitol production.

The species Leuconostoc citreum is often isolated from grain and vegetable fermentations such as sourdough, sauerkraut and kimchi. Lc. citreum has seen an increase in its use as a starter culture for various fermentations and food applications. The strain Lc. citreum TR116 has been applied previously in this laboratory aimed at sugar depletion through metabolism resulting in the reduction of fructose to mannitol, a polyol considered as a sweet carbohydrate. Besides reducing sugar, TR116 showed flavour modulating characteristics and contributes to the extension of microbial shelf life. In order to obtain a better understanding of this strain and to fully use its set of abilities, the genome of Lc. citreum TR116 was sequenced using the Illumina MiSeq, assembly with SPAdes and annotated by the Prokaryotic Genome Annotation Pipeline. Metabolic reconstruction was employed to elucidate carbohydrate, organic acid and amino acid metabolism in the strain. Of particular interest was the gene expression analysis ascertained the influence of fructose on the genes mdh and manX involved in the uptake of fructose and its conversion to mannitol. This investigation, the first in Lc. citreum, illustrates the metabolic processes involved in fermentation used by this strain and demonstrates that in the presence of fructose, expression of the genes mdh and manX is increased. The resulting transparency of the skill set of TR116 contributes highly to future functionalisation of food systems and food ingredients.

Visitor presence and a changing soundscape, alongside environmental parameters, can predict enclosure usage in captive flamingos.

The sound environment of a zoo animal is a complex milieu of animal and human-generated sounds; coming from the species itself, other species, visitors, keepers and other zoo-users. Research determining how different components of the sound environment affect animal behaviour is surprisingly lacking but could have real-world impacts for animal welfare and zoo enclosure design. The current study investigated the effects of the sound environment on two flocks of flamingos housed in open-air enclosures at British zoos. Measures of how each flock used its enclosure (as a response variable) and environmental variables (Inband Power and Peak Frequency were recorded as characteristics of the sound environment, as well as temperature, humidity and cloud cover, and finally visitor presence-all as potential predictor variables) were made over a 2-month period. Assessment of space use by zoo animals is often used as a measure of the appropriateness of an exhibit and to understand welfare. Given that flamingo activity is influenced by weather and that the sound environment of the zoo is likely to be influenced by the number and the presence of visitors, it was assumed that these predictor variables would influence where the flamingos were located at different times of the day. As expected, there was a complicated relationship between enclosure use and Inband Power (average spectral density, a measure of sound energy) in both flocks; visitors generated salient sound but other visitor characteristics such as their physical presence may have impacted the movement of the birds around their enclosures. Results show a complex picture where environmental conditions influence flamingo enclosure usage as well as visitor presence and sounds around/in the enclosure. Findings are not consistent between the two flocks, with one flock demonstrating distinct temporal change to enclosure zone occupancy and the other responsive to humidity and cloud cover variation. We believe enclosure use can provide a valuable indication of how birds react to their soundscape; however, our findings suggest more work is needed to unpick the components of captive sound environments, and their relative effects on how animals use their space.

The Impact of Coronavirus Disease 2019 Pandemic on U.S. and Canadian PICUs.

OBJECTIVES: There are limited reports of the impact of the coronavirus disease 2019 pandemic focused on U.S. and Canadian PICUs. This hypothesis-generating report aims to identify the United States and Canadian trends of coronavirus disease 2019 in PICUs. DESIGN AND SETTING: To better understand how the coronavirus disease 2019 pandemic was affecting U.S. and Canadian PICUs, an open voluntary daily data collection process of Canadian and U.S. PICUs was initiated by Virtual Pediatric Systems, LLC (Los Angeles, CA; http://www.myvps.org) in mid-March 2020. Information was made available online to all PICUs wishing to participate. A secondary data collection was performed to follow-up on patients discharged from those PICUs reporting coronavirus disease 2019 positive patients. MEASUREMENTS AND MAIN RESULTS: To date, over 180 PICUs have responded detailing 530 PICU admissions requiring over 3,467 days of PICU care with 30 deaths. The preponderance of cases was in the eastern regions. Twenty-four percent of the patients admitted to the PICUs were over 18 years old. Fourteen percent of admissions were under 2 years old. Nearly 60% of children had comorbidities at admission with the average length of stay increasing by age and by severity of comorbidity. Advanced respiratory support was necessary during 67% of the current days of care, with 69% being conventional mechanical ventilation. CONCLUSIONS: PICUs have been significantly impacted by the pandemic. They have provided care not only for children but also adults. Patients with coronavirus disease 2019 have a high frequency of comorbidities, require longer stays, more ventilatory support than usual PICU admissions. These data suggest several avenues for further exploration.

Application of mannitol producing Leuconostoc citreum TR116 to reduce sugar content of barley, oat and wheat malt-based worts.

Achieving a high monosaccharide composition in malt wort is instrumental to achieve successful lactic acid bacteria fermentation of malt based beverages. The conversion of monosaccharides to alternative metabolites such as the sweet polyol, mannitol with heterofermentative strains presents a novel approach for sugar reduction and to compensate for the loss of sweetness. This work outlines the application of an adopted mashing regimen with the addition of exogenous enzymes to produce wort with high fructose content which can be applied to different malted grain types with consistently efficacious monosaccharide production for bacterial fermentation. The so produced worts are then fermented with Leuconostoc citreum TR116 a mannitol hyper-producer. Malted barley, oat and wheat were mashed to stimulate protein degradation and release of free amino acids along with the enzymatic conversion of starch to fermentable sugars. Amyloglucosidase and glucose isomerase treatment converted di- and oligo-saccharides to glucose and provided a moderate fructose concentration in malt worts which was consistent across the three cereals. Fructose was completely depleted during fermentation with Lc. Citreum TR116 and converted to mannitol with high efficiency (>90%) while overall sugar reduction was >25% in all malt worts. Differences in amino acid composition of malt worts did not significantly affect growth of Lc. Citreum TR116 but did affect the formation of the aroma compounds diacetyl and isoamyl alcohol. Organic acid production and acidification of wort was similar across cereal substrates and acetic acid formation was linked to yield of mannitol. The results suggest that differences in amino acid and fructose content of malt worts considerably change metabolite formation during fermentation with Lc. Citreum TR116, a mannitol hyper-producer. This work gives new insight into the development of consumer acceptable malt based beverages which will provide further options for the health conscious and diabetic consumer, an important step in the age of sugar overconsumption.

Isolation, characterisation and exploitation of lactic acid bacteria capable of efficient conversion of sugars to mannitol.

The demand for sugar reduction in products across the food and beverage industries has evoked the development of novel processes including the application of fermentation with lactic acid bacteria. Heterofermentative lactic acid bacteria (LAB) are diverse in their ability to utilise fermentable sugars and can also convert fructose into the sweet tasting polyol, mannitol. The sourdough microbiota has long been recognised as an ecological niche for a range of homofermentative and heterofermentative lactic acid bacteria. A leading determinant in the biodiversity of sourdough microbial populations is the type of flour used. Ten non-wheat flours were used and back-slopped for 7 days resulting in the isolation of 52 mannitol producing isolates which spanned six heterofermentative species of the genera Lactobacillus, Leuconostoc and Weissella. Assessment of mannitol productivity in fructose concentrations up to 100 g/L found Leuconostoc citreum TR116, to have the best mannitol producing characteristics, consuming 95% of available fructose and yielding 0.68 g of mannitol per gram of fructose consumed which equates to the maximal theoretical yield. Investigation of the effects of initial pH on mannitol production and other fermentation parameters in the isolates found pH 7 to be best for isolates Lactobacillus brevis TR052, Leuconostoc fallax TR111, Leuconostoc citreum TR116, Leuconostoc mesenteroides TR154 and Weissella paramesenteroides TR212, while pH 6 was optimal for Leuconostoc pseudomesenteroides TR080. The fermentation of apple juice with each isolate resulted in sugar reduction ranging from 30.3-74.0 g/L (34-72%). When apple juice fermentation with Leuconostoc citreum TR116 was scaled up to 1 L bioreactor a reduction in sugar of 98.6 g/L (83%) was achieved along with the production of 61.6 g/L mannitol. This demonstrates a fermentative process for sugar reduction in fruit juice with concomitant production of the sweet metabolite mannitol to create a fermentate that is suitable for further development as a low sugar fruit juice alternative.

A review of polyols - biotechnological production, food applications, regulation, labeling and health effects.

Food research is constantly searching for new ways to replace sugar. This is due to the negative connotations of sugar consumption on health which has driven consumer demand for healthier products and is reflected on a national level by the taxation of sugary beverages. Sugar alcohols, a class of polyols, are present in varying levels in many fruits and vegetables and are also added to foods as low calorific sweeteners. The most commonly used polyols in food include sorbitol, mannitol, xylitol, erythritol, maltitol, lactitol and isomalt. Of these, microorganisms can produce sorbitol, mannitol, xylitol and erythritol either naturally or through genetic engineering. Production of polyols by microbes has been the focus of a lot of research for its potential as an alternative to current industrial scale production by chemical synthesis but can also be used for in situ production of natural sweeteners in fermented products using microbes approved for use in foods. This review on the generation of these natural sweetening compounds by microorganisms examines the current understanding and methods of microbial production of polyols that are applicable in the food industry. The review also considers the health benefits and effects of polyol usage and discusses regulations which are applicable to polyol use.

Criteria for Critical Care Infants and Children: PICU Admission, Discharge, and Triage Practice Statement and Levels of Care Guidance.

OBJECTIVES: To update the American Academy of Pediatrics and Society of Critical Care Medicine's 2004 Guidelines and levels of care for PICU. DESIGN: A task force was appointed by the American College of Critical Care Medicine to follow a standardized and systematic review of the literature using an evidence-based approach. The 2004 Admission, Discharge and Triage Guidelines served as the starting point, and searches in Medline (Ovid), Embase (Ovid), and PubMed resulted in 329 articles published from 2004 to 2016. Only 21 pediatric studies evaluating outcomes related to pediatric level of care, specialized PICU, patient volume, or personnel. Of these, 13 studies were large retrospective registry data analyses, six small single-center studies, and two multicenter survey analyses. Limited high-quality evidence was found, and therefore, a modified Delphi process was used. Liaisons from the American Academy of Pediatrics were included in the panel representing critical care, surgical, and hospital medicine expertise for the development of this practice guidance. The title was amended to "practice statement" and "guidance" because Grading of Recommendations, Assessment, Development, and Evaluation methodology was not possible in this administrative work and to align with requirements put forth by the American Academy of Pediatrics. METHODS: The panel consisted of two groups: a voting group and a writing group. The panel used an iterative collaborative approach to formulate statements on the basis of the literature review and common practice of the pediatric critical care bedside experts and administrators on the task force. Statements were then formulated and presented via an online anonymous voting tool to a voting group using a three-cycle interactive forecasting Delphi method. With each cycle of voting, statements were refined on the basis of votes received and on comments. Voting was conducted between the months of January 2017 and March 2017. The consensus was deemed achieved once 80% or higher scores from the voting group were recorded on any given statement or where there was consensus upon review of comments provided by voters. The Voting Panel was required to vote in all three forecasting events for the final evaluation of the data and inclusion in this work. The writing panel developed admission recommendations by level of care on the basis of voting results. RESULTS: The panel voted on 30 statements, five of which were multicomponent statements addressing characteristics specific to PICU level of care including team structure, technology, education and training, academic pursuits, and indications for transfer to tertiary or quaternary PICU. Of the remaining 25 statements, 17 reached consensus cutoff score. Following a review of the Delphi results and consensus, the recommendations were written. CONCLUSIONS: This practice statement and level of care guidance manuscript addresses important specifications for each PICU level of care, including the team structure and resources, technology and equipment, education and training, quality metrics, admission and discharge criteria, and indications for transfer to a higher level of care. The sparse high-quality evidence led the panel to use a modified Delphi process to seek expert opinion to develop consensus-based recommendations where gaps in the evidence exist. Despite this limitation, the members of the Task Force believe that these recommendations will provide guidance to practitioners in making informed decisions regarding pediatric admission or transfer to the appropriate level of care to achieve best outcomes.

Executive Summary: Criteria for Critical Care of Infants and Children: PICU Admission, Discharge, and Triage Practice Statement and Levels of Care Guidance.

This is an executive summary of the 2019 update of the 2004 guidelines and levels of care for PICU. Since previous guidelines, there has been a tremendous transformation of Pediatric Critical Care Medicine with advancements in pediatric cardiovascular medicine, transplant, neurology, trauma, and oncology as well as improvements of care in general PICUs. This has led to the evolution of resources and training in the provision of care through the PICU. Outcome and quality research related to admission, transfer, and discharge criteria as well as literature regarding PICU levels of care to include volume, staffing, and structure were reviewed and included in this statement as appropriate. Consequently, the purposes of this significant update are to address the transformation of the field and codify a revised set of guidelines that will enable hospitals, institutions, and individuals in developing the appropriate PICU for their community needs. The target audiences of the practice statement and guidance are broad and include critical care professionals; pediatricians; pediatric subspecialists; pediatric surgeons; pediatric surgical subspecialists; pediatric imaging physicians; and other members of the patient care team such as nurses, therapists, dieticians, pharmacists, social workers, care coordinators, and hospital administrators who make daily administrative and clinical decisions in all PICU levels of care.

Sourdough technology as a novel approach to overcome quality losses in sugar-reduced cakes.

Sugar reduction in sweet baked goods is one of the most popular trends on the food market. However, reducing sugar without lowering the product quality with respect to sweetness, texture and microbial shelf life is challenging. Sugar alcohols are one group of sugar replacers which maintain the bulk and contribute to sweetness. Nevertheless, alternative approaches, particularly those that are seen as 'clean label', are highly demanded. Hence, the natural, in situ production of mannitol in a sourdough system was performed and its potential as a functional ingredient to improve the product quality of a sugar-reduced cake was investigated. A full sugar cake (C1), a 50% sugar-reduced cake with wheat starch (C2) or with commercially available mannitol (C3) were considered as controls. The substitution of sugar by wheat starch or mannitol caused lower specific volume (-15.5%; -10.7%), a harder crumb (+17.1 N; +4.4 N), less browning, a shorter microbial shelf life (-5.7 days; -4.3 days) and poorer sensory properties. The incorporation of sourdough in C2 improved the pasting properties by decreasing the peak viscosity. Moreover, it resulted in a similar specific volume to the full-sugar control, contributed to significantly softer crumb (-8.6 N) and increased browning compared to C2. Sensory evaluation revealed an increased sweetness perception (+93%), aroma (+30%) and flavour (+25.5%) by the incorporation of sourdough. Although sourdough incorporation improved sugar-reduced cakes, the quality characteristics of the full-sugar control could not be achieved in this study. In conclusion, the addition of sourdough in amounts lower than 10% can be considered a useful tool to improve specific volume, crumb structure, colour, taste and flavour, as well as shelf life of sugar-reduced cakes.

Leuconostoc citreum TR116: In-situ production of mannitol in sourdough and its application to reduce sugar in burger buns.

A marketing study revealed that commercially available burger buns can contain up to 10% (w/w) of added sugar. In order to reduce sugar and maintaining the product quality at the same time, functional ingredients and alternative sweetening agents have to be incorporated. In this study, the sourdough lactic acid bacteria Leuconostoc citreum TR116, selected for its ability to produce high amounts of mannitol, was used to produce wheat sourdough and its biochemical characteristics (cell count, pH, TTA, sugar- and acid profile, as well as mannitol production) were monitored over 48 h. The so produced sourdough was then incorporated, as a functional ingredient, into a sugar reduced burger bun system and the quality characteristics of the dough and the final product were determined. Sourdough incorporation counteract the negative effects of sugar reduction on dough properties and resulted in the same viscoelastic properties (0.423 ±â€¯0.008) and gluten-network-development (PMT: 160 ±â€¯12.6 s; TM: 44.0 ±â€¯2.6 BU) as the full-sugar control dough. Furthermore, the investigation of specific volume, crumb hardness and chewiness revealed no significant differences between sugar reduced sourdough burger buns and its control. It is noteworthy that sourdough contributed to browning reaction resulting in darker crumb and crust colour (-8.2%; -9.6%) and it extended microbial shelf life of the burger buns significantly (+3.5 days). Sensory evaluation showed no significant differences in sweetness and sourness between sugar reduced buns containing sourdough and the full-sugar control. In conclusion, the incorporation of mannitol-rich sourdough fermented by Leuconostoc citreum TR116 represents a novel technological approach in the field of sugar reduction and showed high potential as a functional ingredient to ameliorate the losses of important quality parameters. Especially sourdough containing higher amounts of mannitol and lower amounts of lactate improved significantly the dough and burger bun quality.

Creation and Implementation of a Pediatric Advanced Practice Nurse Critical Care Fellowship Program.

.

Development and Validation of an Empiric Tool to Predict Favorable Neurologic Outcomes Among PICU Patients.

OBJECTIVES: To create a novel tool to predict favorable neurologic outcomes during ICU stay among children with critical illness. DESIGN: Logistic regression models using adaptive lasso methodology were used to identify independent factors associated with favorable neurologic outcomes. A mixed effects logistic regression model was used to create the final prediction model including all predictors selected from the lasso model. Model validation was performed using a 10-fold internal cross-validation approach. SETTING: Virtual Pediatric Systems (VPS, LLC, Los Angeles, CA) database. PATIENTS: Patients less than 18 years old admitted to one of the participating ICUs in the Virtual Pediatric Systems database were included (2009-2015). INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: A total of 160,570 patients from 90 hospitals qualified for inclusion. Of these, 1,675 patients (1.04%) were associated with a decline in Pediatric Cerebral Performance Category scale by at least 2 between ICU admission and ICU discharge (unfavorable neurologic outcome). The independent factors associated with unfavorable neurologic outcome included higher weight at ICU admission, higher Pediatric Index of Morality-2 score at ICU admission, cardiac arrest, stroke, seizures, head/nonhead trauma, use of conventional mechanical ventilation and high-frequency oscillatory ventilation, prolonged hospital length of ICU stay, and prolonged use of mechanical ventilation. The presence of chromosomal anomaly, cardiac surgery, and utilization of nitric oxide were associated with favorable neurologic outcome. The final online prediction tool can be accessed at https://soipredictiontool.shinyapps.io/GNOScore/. Our model predicted 139,688 patients with favorable neurologic outcomes in an internal validation sample when the observed number of patients with favorable neurologic outcomes was among 139,591 patients. The area under the receiver operating curve for the validation model was 0.90. CONCLUSIONS: This proposed prediction tool encompasses 20 risk factors into one probability to predict favorable neurologic outcome during ICU stay among children with critical illness. Future studies should seek external validation and improved discrimination of this prediction tool.

Pediatric Trauma Assessment and Management Database: Leveraging Existing Data Systems to Predict Mortality and Functional Status after Pediatric Injury.

BACKGROUND: Efforts to improve pediatric trauma outcomes need detailed data, optimally collected at lowest cost, to assess processes of care. We developed a novel database by merging 2 national data systems for 5 pediatric trauma centers to provide benchmarking metrics for mortality and non-mortality outcomes and to assess care provided throughout the care continuum. STUDY DESIGN: Trauma registry and Virtual Pediatric Systems, LLC (VPS) from 5 pediatric trauma centers were merged for children younger than 18 years discharged in 2013 from a pediatric ICU after traumatic injury. For inpatient mortality, we compared risk-adjusted models for trauma registry only, VPS only, and a combination of trauma registry and VPS variables (trauma registry+VPS). To estimate risk-adjusted functional status, we created a prediction model de novo through purposeful covariate selection using dichotomized Pediatric Overall Performance Category scale. RESULTS: Of 688 children included, 77.3% were discharged from the ICU with good performance or mild overall disability and 17.6% with moderate or severe overall disability or coma. Inpatient mortality was 5.1%. The combined dataset provided the best-performing risk-adjusted model for predicting mortality, as measured by the C-statistic, pseudo-R2, and Akaike Information Criterion, when compared with the trauma registry-only model. The final Pediatric Overall Performance Category model demonstrated adequate discrimination (C-statistic = 0.896) and calibration (Hosmer-Lemeshow goodness-of-fit p = 0.65). The probability of poor outcomes varied significantly by site (p < 0.0001). CONCLUSIONS: Merging 2 data systems allowed for improved risk-adjusted modeling for mortality and functional status. The merged database allowed for patient evaluation throughout the care continuum on a multi-institutional level. Merging existing data is feasible, innovative, and has potential to impact care with minimal new resources.

Association of Freestanding Children's Hospitals With Outcomes in Children With Critical Illness.

OBJECTIVES: Little is known about the relationship between freestanding children's hospitals and outcomes in children with critical illness. The purpose of this study was to evaluate the association of freestanding children's hospitals with outcomes in children with critical illness. DESIGN: Propensity score matching was performed to adjust for potential confounding variables between patients cared for in freestanding or nonfreestanding children's hospitals. We tested the sensitivity of our findings by repeating the primary analyses using inverse probability of treatment weighting method and regression adjustment using the propensity score. SETTING: Retrospective study from an existing national database, Virtual PICU Systems (LLC) database. PATIENTS: Patients less than 18 years old admitted to one of the participating PICUs in the Virtual PICU Systems, LLC database were included (2009-2014). INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: A total of 538,967 patients from 140 centers were included. Of these, 323,319 patients were treated in 60 freestanding hospitals. In contrast, 215,648 patients were cared for in 80 nonfreestanding hospitals. By propensity matching, 134,656 patients were matched 1:1 in the two groups (67,328 in each group). Prior to matching, patients in the freestanding hospitals were younger, had greater comorbidities, had higher severity of illness scores, had higher incidence of cardiac arrest, had higher resource utilization, and had higher proportion of patients undergoing complex procedures such as cardiac surgery. Before matching, the outcomes including mortality were worse among the patients cared for in the freestanding hospitals (freestanding vs nonfreestanding, 2.5% vs 2.3%; p < 0.001). After matching, the majority of the study outcomes were better in freestanding hospitals (freestanding vs nonfreestanding, mortality: 2.1% vs 2.8%, p < 0.001; standardized mortality ratio: 0.77 [0.73-0.82] vs 0.99 [0.87-0.96], p < 0.001; reintubation: 3.4% vs 3.8%, p < 0.001; good neurologic outcome: 97.7% vs 97.1%, p = 0.001). CONCLUSIONS: In this large observational study, we demonstrated that ICU care provided in freestanding children's hospitals is associated with improved risk-adjusted survival chances compared to nonfreestanding children's hospitals. However, the clinical significance of this change in mortality should be interpreted with caution. It is also possible that the hospital structure may be a surrogate of other factors that may bias the results.

Impact of 24/7 In-Hospital Intensivist Coverage on Outcomes in Pediatric Intensive Care. A Multicenter Study.

RATIONALE: The around-the-clock presence of an in-house attending critical care physician (24/7 coverage) is purported to be associated with improved outcomes among high-risk children with critical illness. OBJECTIVES: To evaluate the association of 24/7 in-house coverage with outcomes in children with critical illness. METHODS: Patients younger than 18 years of age in the Virtual Pediatric Systems Database (2009-2014) were included. The main analysis was performed using generalized linear mixed effects multivariable regression models. In addition, multiple sensitivity analyses were performed to test the robustness of our findings. MEASUREMENTS AND MAIN RESULTS: A total of 455,607 patients from 125 hospitals were included (24/7 group: 266,319 patients; no 24/7 group: 189,288 patients). After adjusting for patient and center characteristics, the 24/7 group was associated with lower mortality in the intensive care unit (ICU) (24/7 vs. no 24/7; odds ratio [OR], 0.52; 95% confidence interval [CI], 0.33-0.80; P = 0.002), a lower incidence of cardiac arrest (OR, 0.73; 95% CI, 0.54-0.99; P = 0.04), lower mortality after cardiac arrest (OR, 0.56; 95% CI, 0.340-0.93; P = 0.02), a shorter ICU stay (mean difference, -0.51 d; 95% CI, -0.93 to -0.09), and shorter duration of mechanical ventilation (mean difference, -0.68 d; 95% CI, -1.23 to -0.14). CONCLUSIONS: In this large observational study, we demonstrated that pediatric critical care provided in the ICUs staffed with a 24/7 intensivist presence is associated with improved overall patient survival and survival after cardiac arrest compared with patients treated in ICUs staffed with discretionary attending coverage. However, results from a few sensitivity analyses leave some ambiguity in these results.

Risk factors and outcomes of in-hospital cardiac arrest following pediatric heart operations of varying complexity.

BACKGROUND: Multi center data regarding cardiac arrest in children undergoing heart operations of varying complexity are limited. METHODS: Children <18 years undergoing heart surgery (with or without cardiopulmonary bypass) in the Virtual Pediatric Systems (VPS, LLC) Database (2009-2014) were included. Multivariable mixed logistic regression models were adjusted for patient's characteristics, surgical risk category (STS-EACTS Categories 1, 2, and 3 classified as "low" complexity and Categories 4 and 5 classified as "high" complexity), and hospital characteristics. RESULTS: Overall, 26,909 patients (62 centers) were included. Of these, 2.7% had cardiac arrest after cardiac surgery with an associated mortality of 31%. The prevalence of cardiac arrest was lower among patients undergoing low complexity operations (low complexity vs. high complexity: 1.7% vs. 5.9%). Unadjusted outcomes after cardiac arrest were significantly better among patients undergoing low complexity operations (mortality: 21.6% vs. 39.1%, good neurological outcomes: 78.7% vs. 71.6%). In adjusted models, odds of cardiac arrest were significantly lower among patients undergoing low complexity operations (OR: 0.55, 95% CI: 0.46-0.66). Adjusted models, however, showed no difference in mortality or neurological outcomes after cardiac arrest regardless of surgical complexity. Further, our results suggest that incidence of cardiac arrest and mortality after cardiac arrest are a function of patient characteristics, surgical risk category, and hospital characteristics. Presence of around the clock in-house attending level pediatric intensivist coverage was associated with lower incidence of post-operative cardiac arrest, and presence of a dedicated cardiac ICU was associated with lower mortality after cardiac arrest. CONCLUSIONS: This study suggests that the patients undergoing high complexity operations are a higher risk group with increased prevalence of post-operative cardiac arrest. These data further suggest that patients undergoing high complexity operations can be rescued after cardiac arrest with a high survival rate.

Association of house staff training with mortality in children with critical illness.

AIM: To evaluate the association of house staff training with mortality in children with critical illness. METHODS: Patients <18 years of age in the Virtual PICU Systems (VPS, LLC) Database (2009-2013) were included. The study population was divided in two study groups: hospitals with residency programme only and hospitals with both residency and fellowship programme. Control group constituted hospitals with no residency or fellowship programme. The primary study outcome was mortality before intensive care unit (ICU) discharge. Multivariable logistic regression models were fitted to evaluate association of training programmes with ICU mortality. RESULTS: A total of 336 335 patients from 108 centres were included. Case-mix of patients among the hospitals with training programmes was complex; patients cared for in the hospitals with training programmes had greater severity of illness, had higher resource utilisation and had higher overall admission risk of death compared to patients cared for in the control hospitals. Despite caring for more complex and sicker patients, the hospitals with training programmes were associated with lower odds of ICU mortality. CONCLUSION: Our study establishes that ICU care provided in hospitals with training programmes is associated with improved adjusted survival rates among the Virtual PICU database hospitals in the United States.