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Aguilera MN, Hoffman S, Wunderlich W, Watson D, Vacquier M, Sidebottom A. Association of Peripartum Lactate Levels With Infection Outcomes. J Obstet Gynecol Neonatal Nurs 2024; 53:285-295. [PMID: 38281725 DOI: 10.1016/j.jogn.2023.12.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2023] [Revised: 12/19/2023] [Accepted: 12/26/2023] [Indexed: 01/30/2024] Open
Abstract
OBJECTIVE To determine whether lactate levels were associated with maternal infection and infection-related outcomes in the antepartum, intrapartum, and early postpartum periods. DESIGN Retrospective, observational cohort. SETTING Eleven hospitals from a single health system. PARTICIPANTS Women (N = 783) with at least one lactate and blood culture test for obstetric sepsis screening in the antepartum period (n = 154), intrapartum period (n = 348), and early postpartum period (n = 281) from January 2, 2018, to October 21, 2020. METHODS We reported the proportion of participants with adverse outcomes by lactate cut points (≤2.0 and >2.0 mmol/L). We used logistic regression to model the association of infection-related outcomes with lactate levels and calculated receiver operating characteristic curves. RESULTS Lactate was associated with bacteremia among participants in the antepartum period (odds ratio [OR] = 1.60, 95% confidence interval [CI] [1.00, 2.56]) but not among participants in the intrapartum and early postpartum periods. Higher lactate levels were significantly associated with a composite measure of infection-related outcomes (OR = 1.41, 95% CI [1.14, 1.81]), with no differential association by antepartum, intrapartum, or early postpartum periods. Lactate levels were positively associated with intraamniotic infection in the antepartum period (OR = 1.57, 95% CI [1.06, 1.81]) but not in the intrapartum period. The receiver operating characteristic curve indicated that the lactate threshold of 2.0 mmol/L has poor sensitivity. Overall, participants in the antepartum period had lower lactate values than participants in the intrapartum and early postpartum periods. CONCLUSION Lactate levels were not consistently associated with infection-related measures across all periods. We suggest caution when interpreting lactate levels when sepsis is suspected.
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Bodilly L, Williamson L, Lahni P, Alder MN, Haslam DB, Kaplan JM. Obesity Alters cytokine signaling and gut microbiome in septic mice. Innate Immun 2023; 29:161-170. [PMID: 37802127 PMCID: PMC10621470 DOI: 10.1177/17534259231205959] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2022] [Revised: 09/12/2023] [Accepted: 09/20/2023] [Indexed: 10/08/2023] Open
Abstract
Sepsis is a leading cause of mortality. Plasma cytokine levels may identify those at increased risk of mortality from sepsis. Our aim was to understand how obesity alters cytokine levels during early sepsis and its correlation with survival. Six-week-old C57BL/6 male mice were randomized to control (non-obese) or high fat diet (obese) for 5-7 weeks. Sepsis was induced by cecal ligation and perforation (CLP). Cytokine levels were measured from cheek bleeds 8 h after CLP, and mice were monitored for survival. Other cohorts were sacrificed 1 h after CLP for plasma and tissue. Septic obese mice had higher survival. At 8 h after sepsis, obese mice had higher adiponectin, leptin, and resistin but lower TNFα and IL-6 compared to non-obese mice. When stratified by 24-h survival, adipokines were not significantly different in obese and non-obese mice. TNFα and IL-6 were higher in non-obese, compared to obese, mice that died within 24 h of sepsis. Diet and to sepsis significantly impacted the cecal microbiome. IL-6 is a prognostic biomarker during early sepsis in non-obese and obese mice. A plausible mechanism for the survival difference in non-obese and obese mice may be the difference in gut microbiome and its evolution during sepsis.
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Affiliation(s)
- Lauren Bodilly
- Department of Pediatrics, University of Iowa, Iowa City, Iowa, USA
| | - Lauren Williamson
- Division of Critical Care Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - Patrick Lahni
- Division of Critical Care Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - Matthew N. Alder
- Division of Critical Care Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
| | - David B. Haslam
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
- Division of Infectious Diseases, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - Jennifer M. Kaplan
- Division of Critical Care Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
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3
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Yeh CL, Wu JM, Chen KY, Wu MH, Yang PJ, Lee PC, Chen PD, Kuo TC, Yeh SL, Lin MT. Potential therapeutic implications of calcitriol administration and weight reduction on CD4 T cell dysregulation and renin angiotensin system-associated acute lung injury in septic obese mice. Biomed Pharmacother 2023; 165:115127. [PMID: 37423172 DOI: 10.1016/j.biopha.2023.115127] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2023] [Revised: 06/20/2023] [Accepted: 07/02/2023] [Indexed: 07/11/2023] Open
Abstract
This study investigated the effects of weight reduction and/or calcitriol administration on regulating CD4 T cell subsets and renin-angiotensin system (RAS)-associated acute lung injury (ALI) in obese mice with sepsis. Half of the mice were fed a high-fat diet for 16 weeks, half of them had high-fat diet for 12 weeks then were transferred to a low-energy diet for 4 weeks. After feeding the respective diets, cecal ligation and puncture (CLP) were performed to induce sepsis. There were four sepsis groups: OSS group, obese mice injected with saline; OSD group, obese mice given calcitriol; WSS group, mice with weight reduction and saline; WSD group, mice with weight reduction and calcitriol. Mice were sacrificed after CLP. The findings showed that CD4 T subsets distribution did not differ among the experimental groups. Calcitriol-treated groups had higher RAS-associated AT2R, MasR, ACE2, and angiopoietin 1-7 (Ang(1-7)) levels in the lungs. Also, higher tight junction proteins were noted 12 h after CLP. At 24 h post-CLP, weight reduction and/or calcitriol treatment reduced plasma inflammatory mediator production. Calcitriol-treated groups had higher CD4/CD8, T helper (Th)1/Th2 and lower Th17/regulatory T (Treg) ratios than the groups without calcitriol. In the lungs, calcitriol-treated groups had lower AT1R levels, whereas the RAS anti-inflammatory protein levels were higher than those groups without calcitriol. Lower injury scores were also noted at this time point. These findings suggested weight reduction decreased systemic inflammation. However, calcitriol administration produced a more-balanced Th/Treg distribution, upregulated the RAS anti-inflammatory pathway, and attenuated ALI in septic obese mice.
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Affiliation(s)
- Chiu-Li Yeh
- School of Nutrition and Health Sciences, College of Nutrition, Taipei Medical University, Taipei 110, Taiwan; Nutrition Research Center, Taipei Medical University Hospital, Taipei 110, Taiwan
| | - Jin-Ming Wu
- Department of Surgery, National Taiwan University Hospital and College of Medicine, National Taiwan University, Taipei 100, Taiwan
| | - Kuen-Yuan Chen
- Department of Surgery, National Taiwan University Hospital and College of Medicine, National Taiwan University, Taipei 100, Taiwan
| | - Ming-Hsun Wu
- Department of Surgery, National Taiwan University Hospital and College of Medicine, National Taiwan University, Taipei 100, Taiwan
| | - Po-Jen Yang
- Department of Surgery, National Taiwan University Hospital and College of Medicine, National Taiwan University, Taipei 100, Taiwan
| | - Po-Chu Lee
- Department of Surgery, National Taiwan University Hospital and College of Medicine, National Taiwan University, Taipei 100, Taiwan
| | - Po-Da Chen
- Department of Surgery, National Taiwan University Hospital and College of Medicine, National Taiwan University, Taipei 100, Taiwan
| | - Ting-Chun Kuo
- Department of Surgery, National Taiwan University Hospital and College of Medicine, National Taiwan University, Taipei 100, Taiwan
| | - Sung-Ling Yeh
- Department of Surgery, National Taiwan University Hospital and College of Medicine, National Taiwan University, Taipei 100, Taiwan
| | - Ming-Tsan Lin
- Department of Surgery, National Taiwan University Hospital and College of Medicine, National Taiwan University, Taipei 100, Taiwan.
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Davis X, Williamson L, Stuck J, Howell K, Lahni P, Piraino G, Wolfe V, Mukherjee R, Sanchez-Gurmaches J, Zingarelli B, Kaplan J. SEX-DEPENDENT EFFECTS OF ADIPOCYTE STAT3 INHIBITION ON THE INFLAMMATORY RESPONSE DURING SEVERE SEPSIS. Shock 2023; 59:779-790. [PMID: 36840516 PMCID: PMC10149172 DOI: 10.1097/shk.0000000000002105] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/26/2023]
Abstract
ABSTRACT Introduction: Sepsis is a dysregulated host response to infection that can lead to life-threatening organ dysfunction. Clinical and animal studies consistently demonstrate that female subjects are less susceptible to the adverse effects of sepsis, demonstrating the importance of understanding how sex influences sepsis outcomes. The signal transducer and activator of transcription 3 (STAT3) pathway are a major signaling pathway that facilitates inflammation during sepsis. STAT3 is abundantly expressed in white adipose tissue; however, little is known about the contribution of white adipose tissue STAT3 activation during sepsis. We hypothesize that adipocyte STAT3 inhibition during severe sepsis will exaggerate the inflammatory response and impact organ injury, in a sex-dependent manner. Methods: We generated STAT3 flox/flox (wild-type [WT]) and adipocyte STAT3 knock out (A-STAT3 KO) mice using Cre-lox technology. Studies were done in 12- to 16-week-old male and female mice. Polymicrobial sepsis was induced by cecal ligation and puncture (CLP). Control nonseptic mice did not undergo CLP (0 h CLP). Tissues were harvested 18 h after CLP. Body composition was determined by echo magnetic resonance imaging. Energy metabolism was determined by indirect calorimetry. White adipose tissue morphology was determined by hematoxylin and eosin staining, while STAT3 activation in the white adipose tissue was determined by western blot analysis and immunohistochemistry staining of STAT3 activation/phosphorylation at tyrosine 705. Plasma cytokines (TNF-α, IL-6, and leptin) were determined by luminex assay. Neutrophil infiltration of the lung and liver was assessed by myeloperoxidase activity assay. Histological signs of organ injury on lung and liver tissue were assessed by hematoxylin and eosin staining. Liver injury was further assessed by measuring plasma alanine and aspartate aminotransferase. In a separate cohort of mice, sepsis was induced by CLP and mice were monitored every 6-12 h over a 7-day period to assess survival rate. Results: We demonstrate that neither body composition nor energy metabolism is altered with adipocyte STAT3 inhibition in male or female mice, under nonseptic conditions. Sepsis was associated with reduced adipocyte size in female WT and A-STAT3 KO mice, suggesting that this event is STAT3 independent. Sepsis did not alter adipocyte size in male WT and A-STAT3 KO mice, suggesting that this event is also sex dependent. Although STAT3 phosphorylation at tyrosine 705 expression is negligible in male and female A-STAT3 KO mice, septic female WT and A-STAT3 KO mice have higher white adipose tissue STAT3 activation than male WT and A-STAT3 KO mice. Adipocyte STAT3 inhibition did not alter the proinflammatory cytokine response during sepsis in male or female mice, as measured by plasma TNF-α, IL-6, and leptin levels. Adipocyte STAT3 inhibition reduced lung neutrophil infiltration and histological signs of lung injury during sepsis in male mice. On the contrary, adipocyte STAT3 inhibition had no effect on lung neutrophil infiltration or lung injury in female mice. We further demonstrate that neither liver neutrophil infiltration nor histological signs of liver injury are altered by adipocyte STAT3 inhibition during sepsis, in male or female mice. Lastly, adipocyte STAT3 inhibition did not affect survival rate of male or female mice during sepsis. Conclusions: Our study demonstrates that sex influences white adipose tissue STAT3 activation and morphology during sepsis, which is not dependent on the presence of functional STAT3 in mature adipocytes. Furthermore, genetic inhibition of adipocyte STAT3 activation in male, but not female mice, results in reduced lung neutrophil infiltration and lung injury during sepsis. The results from our study demonstrate the importance of considering biological sex and the white adipose tissue as potential sources and targets of inflammation during sepsis.
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Affiliation(s)
- Xenia Davis
- Cincinnati Children’s Hospital Medical Center, Division of Critical Care Medicine, Cincinnati, Ohio
- Department of Pharmacology and Systems Physiology, University of Cincinnati, Cincinnati, Ohio
| | - Lauren Williamson
- Cincinnati Children’s Hospital Medical Center, Division of Critical Care Medicine, Cincinnati, Ohio
| | - Joanna Stuck
- Cincinnati Children’s Hospital Medical Center, Division of Critical Care Medicine, Cincinnati, Ohio
| | - Kendra Howell
- Cincinnati Children’s Hospital Medical Center, Division of Critical Care Medicine, Cincinnati, Ohio
| | - Patrick Lahni
- Cincinnati Children’s Hospital Medical Center, Division of Critical Care Medicine, Cincinnati, Ohio
| | - Giovanna Piraino
- Cincinnati Children’s Hospital Medical Center, Division of Critical Care Medicine, Cincinnati, Ohio
| | - Vivian Wolfe
- Cincinnati Children’s Hospital Medical Center, Division of Critical Care Medicine, Cincinnati, Ohio
| | - Rajib Mukherjee
- Cincinnati Children’s Hospital Medical Center, Division of Endocrinology, Cincinnati, Ohio
| | - Joan Sanchez-Gurmaches
- Cincinnati Children’s Hospital Medical Center, Division of Endocrinology, Cincinnati, Ohio
- Cincinnati Children’s Hospital Medical Center, Division of Developmental Biology, Cincinnati, Ohio
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Basilia Zingarelli
- Cincinnati Children’s Hospital Medical Center, Division of Critical Care Medicine, Cincinnati, Ohio
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Jennifer Kaplan
- Cincinnati Children’s Hospital Medical Center, Division of Critical Care Medicine, Cincinnati, Ohio
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio
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Goldman VE, Espinoza JC, Vidmar AP. Inpatient medical management of severe pediatric obesity: Literature review and case reports. Front Pediatr 2023; 11:1095144. [PMID: 36861081 PMCID: PMC9970259 DOI: 10.3389/fped.2023.1095144] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/10/2022] [Accepted: 01/17/2023] [Indexed: 02/15/2023] Open
Abstract
Pediatric obesity rates continue to rise steeply with significant adverse effects on health outcomes across the lifespan. Significant obesity can affect the efficacy, side effects, and ability to use certain treatment, medication, or imaging modalities needed in the evaluation and management of acute pediatric conditions. Inpatient settings are rarely used as an opportunity for weight counseling and thus there is a paucity of clinical guidelines on how to manage severe obesity in the inpatient setting. We present a literature review and three patient cases with single-center protocol for non-surgical management of severe obesity in children admitted for other acute medical reasons. We performed a PubMed review from January 2002 to February 2022 utilizing keywords: "inpatient," "obesity," and "intervention." For our cases, we identified three patients with severe obesity acutely impacting their health while admitted for medical treatment who concurrently underwent acute, inpatient, weight loss regimens at a single children's hospital. The literature search yielded 33 articles describing inpatient weight loss treatments. Three patients met case criteria, all three of which demonstrated a decrease in their weight in excess percent of the 95th percentile after inpatient weight-management protocol implementation (% reduction BMIp95: 16%-30%). This highlights obesity acutely limits or impacts specific medical care required during inpatient admissions in pediatric patients. It also suggests that implementation of an inpatient weight-management protocol during admission may provide an opportune setting to support acute weight loss and overall improved health outcomes in this high-risk cohort.
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Affiliation(s)
- Victoria E Goldman
- Department of Pediatrics, Children's Hospital Los Angeles, Los Angeles, CA, United States.,Keck School of Medicine of University of Southern California, Los Angeles, CA, United States
| | - Juan C Espinoza
- Department of Pediatrics, Children's Hospital Los Angeles, Los Angeles, CA, United States.,Keck School of Medicine of University of Southern California, Los Angeles, CA, United States
| | - Alaina P Vidmar
- Department of Pediatrics, Children's Hospital Los Angeles, Los Angeles, CA, United States.,Keck School of Medicine of University of Southern California, Los Angeles, CA, United States.,Department of Pediatrics, Endocrinology and Metabolism, Children's Hospital Los Angeles Center for Diabetes, Los Angeles, CA, United States
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6
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Kyler KE, Lee BR, Glynn EF, Waddell JP, Hoffman MA, Goldman JL. Clinical Outcome and Antibiotic Dosing Differences by Weight in Children With Acute Osteomyelitis. Hosp Pediatr 2021; 11:1112-1120. [PMID: 34593567 DOI: 10.1542/hpeds.2021-005890] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
OBJECTIVES To evaluate for weight-based differences in clinical outcomes and antibiotic dosing variability for children hospitalized with acute hematogenous osteomyelitis (AHO). METHODS We performed a retrospective cohort study of children aged 2 to 17 years and hospitalized with a primary AHO International Classification of Diseases, Ninth Revision or International Classification of Diseases, 10th Revision diagnosis code between 2010 and 2017 using the Cerner Health Facts database. Weight categories (healthy, overweight, obesity) were determined by using Centers for Disease Control and Prevention age- and sex-specific BMI percentiles. Rates of procedures, complications, and length of stay (LOS) were compared between groups. Dosing variability between groups was assessed by comparing the initial milligrams per kilogram per day of prescribed antibiotics. RESULTS We identified 755 children with AHO for inclusion. Children with overweight and obesity were more likely to undergo surgical procedures (19% and 17%, respectively) compared with children with a healthy weight (10%; P = .009). They also had a longer LOS (5.7 and 5.8 days) than children with a healthy weight (4.9 days; P = .03). There were no differences in complication rates between weight categories. Mean weight-adjusted daily dose for the most frequently prescribed antibiotics was different by weight category, with children in higher weight categories more likely to receive lower weight-based doses. CONCLUSIONS Children with overweight and obesity hospitalized for AHO were more likely to undergo procedures, have longer LOS, and receive lower weight-based antibiotic dosing compared with children with a healthy weight. Our findings suggest that weight should be carefully considered when treating children with AHO.
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Affiliation(s)
- Kathryn E Kyler
- Children's Mercy Kansas City, Kansas City, Missouri .,Department of Pediatrics, School of Medicine, University of Missouri-Kansas City, Kansas City, Missouri
| | - Brian R Lee
- Children's Mercy Kansas City, Kansas City, Missouri
| | - Earl F Glynn
- Children's Mercy Kansas City, Kansas City, Missouri
| | | | - Mark A Hoffman
- Children's Mercy Kansas City, Kansas City, Missouri.,Department of Pediatrics, School of Medicine, University of Missouri-Kansas City, Kansas City, Missouri.,University of Kansas Medical Center, Kansas City, Kansas
| | - Jennifer L Goldman
- Children's Mercy Kansas City, Kansas City, Missouri.,Department of Pediatrics, School of Medicine, University of Missouri-Kansas City, Kansas City, Missouri
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Thavamani A, Umapathi KK, Sankararaman S, Roy A. Effect of obesity on mortality among hospitalized paediatric patients with severe sepsis. Pediatr Obes 2021; 16:e12777. [PMID: 33719208 DOI: 10.1111/ijpo.12777] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/03/2020] [Accepted: 01/25/2021] [Indexed: 11/28/2022]
Abstract
INTRODUCTION Severe sepsis is one of the leading causes of mortality among children. Studies in adults have suggested a protective effect of obesity on mortality among patients hospitalized with sepsis. Paediatric studies evaluating similar relationship is lacking. METHODS We analysed non-overlapping years of the Kids Inpatient Database (KID) and National Inpatient Sample (NIS) database between 2003 and 2014 of all paediatric patients with severe sepsis (PSS) up to 20 years of age. PSS was defined using specific International Classification of Diseases (ICD) codes and modified Angus criteria. Using ICD-9 diagnosis codes, patients were divided into three mutually exclusive groups (obesity, morbid obesity and control groups), and these groups were compared for outcomes measures including in-hospital mortality and healthcare resource utilization using the length of stay and inflation-adjusted hospitalization charges. RESULTS We analysed 109 026 hospitalizations due to PSS. The prevalence rate of obesity was 1.5% (n = 1643), and morbid obesity was 1.05% (n = 1147). Multivariate regression models showed obesity was associated with 63% (OR 0.37, CI: 0.29-0.47, p < 0.001) and 54% reduction in mortality among PSS patients and patients with septic shock respectively. Contrastingly, morbid obesity was not associated with mortality among PSS patients and but was associated with 1.37 times (CI: 1.06-1.78, p = 0.01) increased risk of mortality among paediatric patients with septic shock. CONCLUSIONS Paediatric obesity is associated with reduced mortality among patients with PSS, with the exception of morbid obesity. Further prospective studies are needed to better understand the relationship between obesity and outcomes in PSS.
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Affiliation(s)
- Aravind Thavamani
- Division of Paediatric Gastroenterology, Hepatology and Nutrition, Department of Paediatrics, UH Rainbow Babies and Children's hospital/Case Western Reserve University School of Medicine, Cleveland, Ohio, USA
| | - Krishna Kishore Umapathi
- Division of Paediatric Cardiology, Department of Paediatrics, Rush University Medical Centre, Chicago, Illinois, USA
| | - Senthilkumar Sankararaman
- Division of Paediatric Gastroenterology, Hepatology and Nutrition, Department of Paediatrics, UH Rainbow Babies and Children's hospital/Case Western Reserve University School of Medicine, Cleveland, Ohio, USA
| | - Aparna Roy
- Division of Paediatric Critical Care, Department of Paediatrics, Metroheath Medical Centre/Case Western Reserve University School of Medicine, Cleveland, Ohio, USA
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Foster BA, Lane JE, Massey E, Noelck M, Green S, Austin JP. The Impact of Malnutrition on Hospitalized Children With Cerebral Palsy. Hosp Pediatr 2020; 10:1087-1095. [PMID: 33154081 PMCID: PMC7684553 DOI: 10.1542/hpeds.2020-0177] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/06/2023]
Abstract
Children with cerebral palsy (CP) and other medical complexity comprise an outsized proportion of health care use. In this review, we describe the current science of assessment of nutritional status for children with CP, outline a systematic approach to assessing their nutritional status, delineate ramifications of malnutrition on hospitalization-associated outcomes, and identify knowledge gaps and means of addressing those gaps using quality improvement and clinical research tools. Methods to accurately assess body composition and adiposity in this population by using skinfolds, age, sex, and activity level are available but are not widely used. There are limitations in our current method of estimating energy needs in children with CP, who are at higher risk of both obesity and micronutrient deficiencies. There is some evidence of an association between malnutrition, defined as either underweight or obesity, and hospitalization-associated outcomes in children generally, although we lack specific data for CP. The gaps in our current understanding of optimal nutritional status and between current science and practice need to be addressed to improve health outcomes for this vulnerable patient population.
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Affiliation(s)
| | - Jennifer E Lane
- Doernbecher Children's Hospital, Oregon Health & Science University, Portland, Oregon
| | - Elizabeth Massey
- Doernbecher Children's Hospital, Oregon Health & Science University, Portland, Oregon
| | - Michelle Noelck
- Doernbecher Children's Hospital, Oregon Health & Science University, Portland, Oregon
| | - Sarah Green
- Doernbecher Children's Hospital, Oregon Health & Science University, Portland, Oregon
| | - Jared P Austin
- Doernbecher Children's Hospital, Oregon Health & Science University, Portland, Oregon
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Huizinga GP, Singer BH, Singer K. The Collision of Meta-Inflammation and SARS-CoV-2 Pandemic Infection. Endocrinology 2020; 161:bqaa154. [PMID: 32880654 PMCID: PMC7499583 DOI: 10.1210/endocr/bqaa154] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/13/2020] [Accepted: 08/25/2020] [Indexed: 02/06/2023]
Abstract
The coronavirus disease 2019 (COVID-19) pandemic has forced us to consider the physiologic role of obesity in the response to infectious disease. There are significant disparities in morbidity and mortality by sex, weight, and diabetes status. Numerous endocrine changes might drive these varied responses to severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection, including hormone and immune mediators, hyperglycemia, leukocyte responses, cytokine secretion, and tissue dysfunction. Studies of patients with severe COVID-19 disease have revealed the importance of innate immune responses in driving immunopathology and tissue injury. In this review we will describe the impact of the metabolically induced inflammation (meta-inflammation) that characterizes obesity on innate immunity. We consider that obesity-driven dysregulation of innate immune responses may drive organ injury in the development of severe COVID-19 and impair viral clearance.
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Affiliation(s)
- Gabrielle P Huizinga
- Graduate Program in Immunology, University of Michigan Medical School, Ann Arbor, Michigan
| | - Benjamin H Singer
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, Michigan
- Michigan Center for Integrative Research in Critical Care, University of Michigan Medical School, Ann Arbor, Michigan
| | - Kanakadurga Singer
- Department of Pediatrics and Department of Molecular and Integrative Physiology, University of Michigan Medical School, Ann Arbor, Michigan
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Kalani C, Venigalla T, Bailey J, Udeani G, Surani S. Sepsis Patients in Critical Care Units with Obesity: Is Obesity Protective? Cureus 2020; 12:e6929. [PMID: 32190482 PMCID: PMC7067368 DOI: 10.7759/cureus.6929] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
Obesity is becoming a global health issue and its prevalence is increasing. It is associated with an increased incidence of illness and sepsis. While obesity is associated with increased morbidity and mortality, obesity has been found to be associated with improvement in mortality outcomes in sepsis when compared to leaner patients, a phenomenon described as an obesity paradox. However, the effect of obesity on mortality in adults requiring treatment for sepsis is unclear. Studies evaluating this effect are inconsistent and there is an increased morbidity still associated with obesity. As well, there are many limitations to these studies confounding interpretation. Future prospective studies minimizing bias and confounding factors are suggested to address this important clinical issue.
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Affiliation(s)
- Charlene Kalani
- Medicine, Corpus Christi Medical Center, Corpus Christi, USA
| | - Tejaswi Venigalla
- Internal Medicine, Corpus Christi Medical Center, Corpus Christi, USA
| | - Janay Bailey
- Internal Medicine, Hunterdon Medical Center, Flemington, USA
| | - George Udeani
- Internal Medicine, Texas A&M University, Kingsville, USA
| | - Salim Surani
- Internal Medicine, Texas A&M Health Science Center, Bryan, USA
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Kyler KE, Bettenhausen JL, Hall M, Hampl S. Prevalence and Trends in Obesity Among Hospitalized Children. Hosp Pediatr 2019; 9:897-902. [PMID: 31645359 DOI: 10.1542/hpeds.2019-0046] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
OBJECTIVES As obesity rates rise in children, it is likely that the number of hospitalized children with obesity is also increasing. However, characterization of the inpatient population with obesity as a whole has not been reported. We aimed to examine trends in the annual prevalence of obesity in hospitalized children and to identify demographic and clinical characteristics associated with higher obesity prevalence in children who are hospitalized. METHODS We completed a retrospective cohort analysis of children aged 2 to 19 years admitted to a single tertiary children's hospital system for any reason in 2009-2016. Body mass index was calculated from documented height and weight. Children with obesity were defined by using age- and sex-specific body mass index percentile guidelines established by the Centers for Disease Control and Prevention. Annual obesity prevalence was calculated on the encounter level for service line and All Patients Refined Diagnosis-Related Groups (diagnosis groups). χ2 tests were used to determine statistical differences between groups, and the Cochran-Armitage test of trend was used to describe changes in obesity over time. RESULTS Of 83 329 children who were hospitalized, 17.0% had obesity, increasing from 16.5% of hospitalizations in 2009-2010 to 17.3% in 2015-2016 (P = .002). Service lines with the highest obesity prevalence included orthopedics (22.1%), infectious disease (20.6%), and neuroscience (18.7%). Diagnosis groups with the highest obesity prevalence included cellulitis (22.5%), tonsil/adenoid procedures (22.0%), and some orthopedic procedures (28.7%). CONCLUSIONS Some groups of children who were hospitalized experience higher obesity prevalence, including children hospitalized with orthopedic, infectious disease, and neurologic problems. In future research, investigators should target disproportionately affected groups by examining health outcomes, patient safety, and satisfaction issues.
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Affiliation(s)
| | | | - Matthew Hall
- Division of Hospital Medicine and
- Children's Hospital Association, Lenexa, Kansas
| | - Sarah Hampl
- Center for Children's Healthy Lifestyles and Nutrition, Children's Mercy Kansas City, Kansas City, Missouri; and
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Ross PA, Klein MJ, Nguyen T, Leung D, Khemani RG, Newth CJL, Bhalla AK. Body Habitus and Risk of Mortality in Pediatric Sepsis and Septic Shock: A Retrospective Cohort Study. J Pediatr 2019; 210:178-183.e2. [PMID: 31036411 DOI: 10.1016/j.jpeds.2019.03.027] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/10/2019] [Revised: 03/18/2019] [Accepted: 03/18/2019] [Indexed: 12/16/2022]
Abstract
OBJECTIVE To investigate the association between body habitus and mortality in critically ill children with sepsis or septic shock. STUDY DESIGN This was a retrospective cohort study of prospectively collected data of children admitted to US pediatric intensive care units (PICUs) with a primary or secondary diagnosis of sepsis or septic shock. We separated body habitus into underweight, normal weight, overweight, and obese. Outcomes were mortality (primary), treatment with invasive mechanical ventilation (secondary), and time to PICU discharge for survivors (secondary). Multivariable analyses using mixed-effects logistic regression and shared frailty models clustered by unit and adjusted for confounding variables were used to assess the association between body habitus and outcomes. RESULTS There were 7038 children with sepsis or septic shock. Mortality was 10.1% (n = 714) and 52.9% (n = 3720) required invasive mechanical ventilation. Body habitus was not associated with mortality after controlling for hospital level effects and confounding variables. Children who were overweight and obese had greater odds of invasive mechanical ventilation (overweight OR 1.23 [95% CI 1.05-1.45], P = .011 and obese OR 1.57 [95% CI 1.37-1.80], P < .001) compared with children of normal weight. In survivors treated with invasive mechanical ventilation, children who were obese had a longer time to PICU discharge than children of normal weight (obese hazard ratio for discharge 0.84 [95% CI, 0.77-0.92], P < .0001). CONCLUSIONS There was no association between body habitus and mortality in critically ill children with sepsis. Children who were overweight and obese were more likely to receive invasive mechanical ventilation and mechanically ventilated survivors who were obsese had a longer time to PICU discharge.
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Affiliation(s)
- Patrick A Ross
- Department of Anesthesiology Critical Care Medicine, Children's Hospital Los Angeles, Keck School of Medicine, University of Southern California, Los Angeles, CA.
| | - Margaret J Klein
- Department of Anesthesiology Critical Care Medicine, Children's Hospital Los Angeles, Los Angeles, CA
| | - Tuan Nguyen
- Department of Pediatrics, Miller Children's and Women's Hospital of Long Beach, Long Beach, CA
| | - Dennis Leung
- Department of Pediatrics, University of North Carolina Healthcare Children's Hospital, Chapel Hill, NC
| | - Robinder G Khemani
- Department of Anesthesiology Critical Care Medicine, Children's Hospital Los Angeles, Keck School of Medicine, University of Southern California, Los Angeles, CA
| | - Christopher J L Newth
- Department of Anesthesiology Critical Care Medicine, Children's Hospital Los Angeles, Keck School of Medicine, University of Southern California, Los Angeles, CA
| | - Anoopindar K Bhalla
- Department of Anesthesiology Critical Care Medicine, Children's Hospital Los Angeles, Keck School of Medicine, University of Southern California, Los Angeles, CA
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Peterson LS, Gállego Suárez C, Segaloff HE, Griffin C, Martin ET, Odetola FO, Singer K. Outcomes and Resource Use Among Overweight and Obese Children With Sepsis in the Pediatric Intensive Care Unit. J Intensive Care Med 2018; 35:472-477. [PMID: 29471722 DOI: 10.1177/0885066618760541] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Abstract
OBJECTIVE To evaluate the effect of overweight and obesity on outcomes and resource use among patients with sepsis in the pediatric intensive care unit (PICU). DESIGN Retrospective analysis of clinical characteristics, resource use, and mortality among children 0 to 20 years of age admitted to the C.S. MottChildren's Hospital PICU (University of Michigan) between January 2009 and December 2015, with a diagnostic code for sepsis at admission (based on International Classification of Diseases, Ninth Revision-Clinical Modification codes) and with weight and height measurements at PICU admission. MEASUREMENTS AND MAIN RESULTS A total of 454 participants met the inclusion criteria. Seventy-six were categorized as underweight (body mass index [BMI] percentile <5th) and were excluded, which left a final sample size of 378 participants. Children with a BMI >5th and <85th percentiles for age were categorized as normal weight and those with a BMI >85th percentile as overweight/obese. After descriptive and bivariate analyses, multivariate regression methods were used to assess the independent effect of obesity status on mortality and the use of PICU technology after adjustment for patient age and illness severity at admission. Of the 378 patients studied, 41.3% were overweight/obese. There was no difference in microbiologic etiology of sepsis (P = .36), median PICU length of stay in days (5.4 vs 5.6; P = .61), or PICU mortality (6.4% vs 7.2%; P = .76) by weight status. The use of specialized PICU technology including extracorporeal membrane oxygenation (odds ratio [OR]: 2.77, 95% confidence interval [CI]:1.13-6.79) and continuous renal replacement therapy (OR: 4.58, 95% CI: 1.16-18.0) was higher among overweight/obese patients, compared with normal weight patients. CONCLUSIONS Although PICU mortality and length of stay were similar for obese-overweight patients and normal weight critically ill children with sepsis, there was significantly higher use of specialized organ-supportive technology among obese patients, likely indicating higher occurrence of multiple organ dysfunction.
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Affiliation(s)
- Laura S Peterson
- Department of Pediatrics and Communicable Diseases, University of Michigan, Ann Arbor, MI, USA
| | - Cecilia Gállego Suárez
- Division of Pediatric Endocrinology and Metabolism, Department of Pediatrics and Communicable Diseases, University of Michigan, Ann Arbor, MI, USA
| | - Hannah E Segaloff
- Department of Epidemiology, School of Public Health, University of Michigan, Ann Arbor, MI, USA
| | - Cameron Griffin
- Division of Pediatric Endocrinology and Metabolism, Department of Pediatrics and Communicable Diseases, University of Michigan, Ann Arbor, MI, USA
| | - Emily T Martin
- Department of Epidemiology, School of Public Health, University of Michigan, Ann Arbor, MI, USA
| | - Folafoluwa O Odetola
- Division of Critical Care Medicine, Department of Pediatrics and Communicable Diseases, University of Michigan, Ann Arbor, MI, USA
| | - Kanakadurga Singer
- Division of Pediatric Endocrinology and Metabolism, Department of Pediatrics and Communicable Diseases, University of Michigan, Ann Arbor, MI, USA
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