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Kahleova H, Brennan H, Znayenko-Miller T, Holubkov R, Barnard ND. Does diet quality matter? A secondary analysis of a randomized clinical trial. Eur J Clin Nutr 2024; 78:270-273. [PMID: 38012413 DOI: 10.1038/s41430-023-01371-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2023] [Revised: 10/31/2023] [Accepted: 11/09/2023] [Indexed: 11/29/2023]
Abstract
This secondary analysis assessed the association of a plant-based index (PDI), healthful (hPDI), and unhealthful (uPDI), with weight loss in overweight adults. Participants (n = 244) were randomly assigned to a vegan (n = 122) or control group (n = 122) for 16 weeks. Three-day dietary records were analyzed and PDI indices were calculated. A repeated measure ANOVA was used for statistical analysis. All three scores increased in the vegan group; the effect sizes were: PDI +10.6 (95% CI +8.6 to +12.6; p < 0.001); hPDI +10.9 (95% CI +8.4 to +13.4; p < 0.001); and uPDI +5.4 (95% CI +3.4 to +7.4; p < 0.001). The change in all three scores significantly correlated with change in body weight: PDI (r = -0.40; p < 0.001); hPDI (r = -0.37; p < 0.001); and uPDI (r = -0.21; p = 0.002). These findings suggest that minimizing the consumption of animal products and oil may be an effective weight loss strategy in overweight adults. ClinicalTrials.gov number, NCT02939638.
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Affiliation(s)
- Hana Kahleova
- Physicians Committee for Responsible Medicine, Washington, DC, USA.
| | - Haley Brennan
- Physicians Committee for Responsible Medicine, Washington, DC, USA
| | | | | | - Neal D Barnard
- Physicians Committee for Responsible Medicine, Washington, DC, USA
- Adjunct faculty, George Washington University School of Medicine and Health Sciences, Washington, DC, USA
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2
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Steinberg BA, Holubkov R, Deering T, Groh CA, Mittal S, Kennedy R, Pokharel P, Perez M, Savona S, Verma N, Watt K, Piccini JP, Bunch TJ. Expedited loading with intravenous sotalol is safe and feasible-primary results of the Prospective Evaluation Analysis and Kinetics of IV Sotalol (PEAKS) Registry. Heart Rhythm 2024:S1547-5271(24)00218-2. [PMID: 38417598 DOI: 10.1016/j.hrthm.2024.02.046] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/30/2023] [Revised: 02/20/2024] [Accepted: 02/22/2024] [Indexed: 03/01/2024]
Abstract
BACKGROUND Loading of oral sotalol for atrial fibrillation requires 3 days, frequently in the hospital, to achieve steady state. The Food and Drug Administration approved loading with intravenous (IV) sotalol through model-informed development, without patient data. OBJECTIVE We present results of the first multicenter evaluation of this recent labeling for IV sotalol. METHODS The Prospective Evaluation Analysis and Kinetics of IV Sotalol (PEAKS) Registry was a multicenter observational registry of patients undergoing elective IV sotalol load for atrial arrhythmias. Outcomes, measured from hospital admission until first outpatient follow-up, included adverse arrhythmia events, efficacy, and length of stay. RESULTS Of 167 consecutively enrolled patients, 23% were female; the median age was 68 (interquartile range, 61-74) years, and the median CHA2DS2-VASc score was 3 (interquartile range, 2-4). Overall, 99% were admitted for sotalol initiation (1% for dose escalation), with a target oral sotalol dose of either 80 mg twice daily (85 [51%]) or 120 mg twice daily (78 [47%]); 62 patients (37%) had an estimated creatinine clearance ≤90 mL/min. On presentation, 40% of patients were in sinus rhythm, whereas 26% underwent cardioversion before sotalol infusion. In 2 patients, sotalol infusion was stopped for bradycardia or hypotension. In 6 patients, sotalol was discontinued before discharge because of QTc prolongation (3), bradycardia (1), or recurrent atrial arrhythmia (2). The mean length of stay was 1.1 days, and 95% (n = 159) were discharged within 1 night. CONCLUSION IV sotalol loading is safe and feasible for atrial arrhythmias, with low rates of adverse events, and yields shorter hospitalizations. More data are needed on the minimal duration required for monitoring in the hospital.
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Affiliation(s)
- Benjamin A Steinberg
- Division of Cardiovascular Medicine, University of Utah Health, Salt Lake City, Utah.
| | - Richard Holubkov
- Data Coordinating Center, Department of Pediatrics, Spencer Eccles Fox School of Medicine, University of Utah, Salt Lake City, Utah
| | | | - Christopher A Groh
- Division of Cardiovascular Medicine, University of Utah Health, Salt Lake City, Utah
| | | | | | | | - Marco Perez
- Department of Medicine, Stanford University, Stanford, California
| | - Salvatore Savona
- Department of Medicine, The Ohio State University, Columbus, Ohio
| | - Nishant Verma
- Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Kevin Watt
- Division of Clinical Pharmacology, Department of Pediatrics, Spencer Eccles Fox School of Medicine, University of Utah, Salt Lake City, Utah
| | - Jonathan P Piccini
- Department of Medicine, Duke University Medical Center, Durham, North Carolina
| | - T Jared Bunch
- Division of Cardiovascular Medicine, University of Utah Health, Salt Lake City, Utah
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3
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Cabler SS, Storch GA, Weinberg JB, Walton AH, Brengel-Pesce K, Aldewereld Z, Banks RK, Cheynet V, Reeder R, Holubkov R, Berg RA, Wessel D, Pollack MM, Meert K, Hall M, Newth C, Lin JC, Cornell T, Harrison RE, Dean JM, Carcillo JA. Viral DNAemia and DNA Virus Seropositivity and Mortality in Pediatric Sepsis. JAMA Netw Open 2024; 7:e240383. [PMID: 38407904 PMCID: PMC10897747 DOI: 10.1001/jamanetworkopen.2024.0383] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/20/2023] [Accepted: 01/05/2024] [Indexed: 02/27/2024] Open
Abstract
Importance Sepsis is a leading cause of pediatric mortality. Little attention has been paid to the association between viral DNA and mortality in children and adolescents with sepsis. Objective To assess the association of the presence of viral DNA with sepsis-related mortality in a large multicenter study. Design, Setting, and Participants This cohort study compares pediatric patients with and without plasma cytomegalovirus (CMV), Epstein-Barr virus (EBV), herpes simplex virus 1 (HSV-1), human herpesvirus 6 (HHV-6), parvovirus B19 (B19V), BK polyomavirus (BKPyV), human adenovirus (HAdV), and torque teno virus (TTV) DNAemia detected by quantitative real-time polymerase chain reaction or plasma IgG antibodies to CMV, EBV, HSV-1, or HHV-6. A total of 401 patients younger than 18 years with severe sepsis were enrolled from 9 pediatric intensive care units (PICUs) in the Eunice Kennedy Shriver National Institute of Child Health and Human Development Collaborative Pediatric Critical Care Research Network. Data were collected from 2015 to 2018. Samples were assayed from 2019 to 2022. Data were analyzed from 2022 to 2023. Main Outcomes and Measures Death while in the PICU. Results Among the 401 patients included in the analysis, the median age was 6 (IQR, 1-12) years, and 222 (55.4%) were male. One hundred fifty-four patients (38.4%) were previously healthy, 108 (26.9%) were immunocompromised, and 225 (56.1%) had documented infection(s) at enrollment. Forty-four patients (11.0%) died in the PICU. Viral DNAemia with at least 1 virus (excluding TTV) was detected in 191 patients (47.6%) overall, 63 of 108 patients (58.3%) who were immunocompromised, and 128 of 293 (43.7%) who were not immunocompromised at sepsis onset. After adjustment for age, Pediatric Risk of Mortality score, previously healthy status, and immunocompromised status at sepsis onset, CMV (adjusted odds ratio [AOR], 3.01 [95% CI, 1.36-6.45]; P = .007), HAdV (AOR, 3.50 [95% CI, 1.46-8.09]; P = .006), BKPyV (AOR. 3.02 [95% CI, 1.17-7.34]; P = .02), and HHV-6 (AOR, 2.62 [95% CI, 1.31-5.20]; P = .007) DNAemia were each associated with increased mortality. Two or more viruses were detected in 78 patients (19.5%), with mortality among 12 of 32 (37.5%) who were immunocompromised and 9 of 46 (19.6%) who were not immunocompromised at sepsis onset. Herpesvirus seropositivity was common (HSV-1, 82 of 246 [33.3%]; CMV, 107 of 254 [42.1%]; EBV, 152 of 251 [60.6%]; HHV-6, 253 if 257 [98.4%]). After additional adjustment for receipt of blood products in the PICU, EBV seropositivity was associated with increased mortality (AOR, 6.10 [95% CI, 1.00-118.61]; P = .049). Conclusions and Relevance The findings of this cohort study suggest that DNAemia for CMV, HAdV, BKPyV, and HHV-6 and EBV seropositivity were independently associated with increased sepsis mortality. Further investigation of the underlying biology of these viral DNA infections in children with sepsis is warranted to determine whether they only reflect mortality risk or contribute to mortality.
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Affiliation(s)
- Stephanie S. Cabler
- Department of Pediatrics, Washington University in St Louis, St Louis, Missouri
| | - Gregory A. Storch
- Department of Pediatrics, Washington University in St Louis, St Louis, Missouri
| | | | - Andrew H. Walton
- Department of Pediatrics, Washington University in St Louis, St Louis, Missouri
| | | | - Zachary Aldewereld
- Department of Pediatrics and Critical Care Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| | | | | | - Ron Reeder
- Department of Pediatrics, University of Utah, Salt Lake City
| | | | - Robert A. Berg
- Department of Anesthesiology, Pediatrics, University of Pennsylvania, Philadelphia
| | - David Wessel
- Department of Pediatrics, George Washington University, Washington, DC
| | - Murray M. Pollack
- Department of Pediatrics, George Washington University, Washington, DC
| | - Kathleen Meert
- Department of Pediatrics, Central Michigan University, Detroit
| | - Mark Hall
- Department of Pediatrics, The Ohio State University, Columbus
| | - Christopher Newth
- Department of Anesthesiology, University of Southern California, Los Angeles
| | - John C. Lin
- Department of Pediatrics, Washington University in St Louis, St Louis, Missouri
| | - Tim Cornell
- Department of Pediatrics, University of Michigan, Ann Arbor
| | | | - J. Michael Dean
- Department of Pediatrics, University of Utah, Salt Lake City
| | - Joseph A. Carcillo
- Department of Pediatrics and Critical Care Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
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Kirschenbaum MD, Hu KS, Ip CS, Lin A, Pierce J, Holubkov R, Jensen H, Mifflin MD. One-Year Results of a Phase I/II Randomized, Double-Masked, Placebo-Controlled Study of Processed Amniotic Fluid Drops After PRK. Cornea 2024:00003226-990000000-00463. [PMID: 38277050 DOI: 10.1097/ico.0000000000003474] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2023] [Accepted: 12/06/2023] [Indexed: 01/27/2024]
Abstract
PURPOSE The aim of this study was to evaluate the 1-year outcomes of using processed amniotic fluid (pAF) postoperatively after photorefractive keratectomy (PRK). METHODS Sixty-one participants were randomized to receive either placebo or pAF drops. The drops were instilled 4 times daily for 1 week after PRK along with routine postoperative medications. The primary outcome measures included uncorrected visual acuity, topographic corneal irregularity measurement, and surface staining over 1 year. RESULTS A statistically significant difference in uncorrected distance visual acuity between the placebo and treatment groups was seen at 1 month post-PRK, with a visual advantage evident in the pAF group. A suggestive difference in corneal irregularity measurement was also seen between the placebo and treatment groups at 1 month postsurgery, with less irregularity noted in the pAF group. No differences in uncorrected distance visual acuity or corneal irregularity measurement were found at 3, 6, and 12 months. There was also no significant difference in corneal staining scores between the 2 groups at any of the measured time points. CONCLUSIONS This 1-year study evaluating the safety and efficacy of pAF as an additional postoperative topical medication after PRK demonstrated that pAF offered a mild visual advantage at 1 month post-PRK. There were no late adverse events, and the intervention proved safe at 1 year.
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Affiliation(s)
- Malka Davina Kirschenbaum
- Department of Ophthalmology and Visual Sciences, John A. Moran Eye Center, University of Utah, Salt Lake City, UT
| | - Katherine S Hu
- Department of Ophthalmology and Visual Sciences, John A. Moran Eye Center, University of Utah, Salt Lake City, UT
| | - Colin S Ip
- Department of Ophthalmology and Visual Sciences, John A. Moran Eye Center, University of Utah, Salt Lake City, UT
| | - Amy Lin
- Department of Ophthalmology and Visual Sciences, John A. Moran Eye Center, University of Utah, Salt Lake City, UT
| | - Jan Pierce
- Cell Therapy and Regenerative Medicine, University of Utah, Salt Lake City, UT; and
| | - Richard Holubkov
- Department of Pediatrics, University of Utah, Salt Lake City, UT
| | - Hailey Jensen
- Department of Pediatrics, University of Utah, Salt Lake City, UT
| | - Mark D Mifflin
- Department of Ophthalmology and Visual Sciences, John A. Moran Eye Center, University of Utah, Salt Lake City, UT
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VanBuren JM, Hall M, Zuppa AF, Mourani PM, Carcillo J, Dean JM, Watt K, Holubkov R. The Design of Nested Adaptive Clinical Trials of Multiple Organ Dysfunction Syndrome Children in a Single Study. Pediatr Crit Care Med 2023; 24:e635-e646. [PMID: 37498156 PMCID: PMC10817996 DOI: 10.1097/pcc.0000000000003332] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/28/2023]
Abstract
OBJECTIVES Describe the statistical design of the Personalized Immunomodulation in Sepsis-induced Multiple Organ Dysfunction Syndrome (MODS) (PRECISE) study. DESIGN Children with sepsis-induced MODS undergo real-time immune testing followed by assignment to an immunophenotype-specific study cohort. Interventional cohorts include the granulocyte macrophage-colony stimulating factor (GM-CSF) for the Reversal of Immunoparalysis in Pediatric Sepsis-induced MODS (GRACE)-2 trial, which uses the drug GM-CSF (or placebo) to reverse immunoparalysis; and the Targeted Reversal of Inflammation in Pediatric Sepsis-induced MODS (TRIPS) trial, which uses the drug anakinra (or placebo) to reverse systemic inflammation. Both trials have adaptive components and use a statistical framework in which frequent data monitoring assesses futility and efficacy, allowing potentially earlier stopping than traditional approaches. Prespecified simulation-based stopping boundaries are customized to each trial to preserve an overall one-sided type I error rate. The TRIPS trial also uses response-adaptive randomization, updating randomization allocation proportions to favor active arms that appear more efficacious based on accumulating data. SETTING Twenty-four U.S. academic PICUs. PATIENTS Septic children with specific immunologic derangements during ongoing dysfunction of at least two organs. INTERVENTIONS The GRACE-2 trial compares GM-CSF and placebo in children with immunoparalysis. The TRIPS trial compares four different doses of anakinra to placebo in children with moderate to severe systemic inflammation. MEASUREMENTS AND MAIN RESULTS Both trials assess primary efficacy using the sum of the daily pediatric logistic organ dysfunction-2 score over 28 days. Ranked summed scores, with mortality assigned the worst possible value, are compared between arms using the Wilcoxon Rank Sum test (GRACE-2) and a dose-response curve (TRIPS). We present simulation-based operating characteristics under several scenarios to demonstrate the behavior of the adaptive design. CONCLUSIONS The adaptive design incorporates innovative statistical features that allow for multiple active arms to be compared with placebo based on a child's personal immunophenotype. The design increases power and provides optimal operating characteristics compared with traditional conservative methods.
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Affiliation(s)
- John M VanBuren
- Department of Pediatrics, University of Utah, Salt Lake City, UT
| | - Mark Hall
- Department of Pediatrics, Division of Critical Care Medicine, Nationwide Children's Hospital, Columbus, OH
| | - Athena F Zuppa
- Department of Anesthesia and Critical Care, Division of Critical Care Medicine, Children's Hospital of Philadelphia, Philadelphia, PA
| | - Peter M Mourani
- Department of Pediatrics, Division of Critical Care Medicine, University of Arkansas for Medical Sciences and Arkansas Children's Research Institute, Little Rock, AR
| | - Joseph Carcillo
- Department of Critical Care Medicine and Pediatrics, University of Pittsburgh, Children's Hospital of Pittsburgh, UPMC Children's Hospital of Pittsburgh, Pittsburgh, PA
| | - J Michael Dean
- Department of Pediatrics, University of Utah, Salt Lake City, UT
| | - Kevin Watt
- Department of Pediatrics, University of Utah, Salt Lake City, UT
| | - Richard Holubkov
- Department of Pediatrics, University of Utah, Salt Lake City, UT
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6
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Podd BS, Banks RK, Reeder R, Telford R, Holubkov R, Carcillo J, Berg RA, Wessel D, Pollack MM, Meert K, Hall M, Newth C, Lin JC, Doctor A, Shanley T, Cornell T, Harrison RE, Zuppa AF, Sward K, Dean JM, Randolph AG. Early, Persistent Lymphopenia Is Associated With Prolonged Multiple Organ Failure and Mortality in Septic Children. Crit Care Med 2023; 51:1766-1776. [PMID: 37462434 DOI: 10.1097/ccm.0000000000005993] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2023]
Abstract
OBJECTIVES Sepsis-associated immune suppression correlates with poor outcomes. Adult trials are evaluating immune support therapies. Limited data exist to support consideration of immunomodulation in pediatric sepsis. We tested the hypothesis that early, persistent lymphopenia predicts worse outcomes in pediatric severe sepsis. DESIGN Observational cohort comparing children with severe sepsis and early, persistent lymphopenia (absolute lymphocyte count < 1,000 cells/µL on 2 d between study days 0-5) to children without. The composite outcome was prolonged multiple organ dysfunction syndrome (MODS, organ dysfunction beyond day 7) or PICU mortality. SETTING Nine PICUs in the National Institutes of Health Collaborative Pediatric Critical Care Research Network between 2015 and 2017. PATIENTS Children with severe sepsis and indwelling arterial and/or central venous catheters. INTERVENTIONS Blood sampling and clinical data analysis. MEASUREMENTS AND MAIN RESULTS Among 401 pediatric patients with severe sepsis, 152 (38%) had persistent lymphopenia. These patients were older, had higher illness severity, and were more likely to have underlying comorbidities including solid organ transplant or malignancy. Persistent lymphopenia was associated with the composite outcome prolonged MODS or PICU mortality (66/152, 43% vs 45/249, 18%; p < 0.01) and its components prolonged MODS (59/152 [39%] vs 43/249 [17%]), and PICU mortality (32/152, 21% vs 12/249, 5%; p < 0.01) versus children without. After adjusting for baseline factors at enrollment, the presence of persistent lymphopenia was associated with an odds ratio of 2.98 (95% CI [1.85-4.02]; p < 0.01) for the composite outcome. Lymphocyte count trajectories showed that patients with persistent lymphopenia generally did not recover lymphocyte counts during the study, had lower nadir whole blood tumor necrosis factor-α response to lipopolysaccharide stimulation, and higher maximal inflammatory markers (C-reactive protein and ferritin) during days 0-3 ( p < 0.01). CONCLUSIONS Children with severe sepsis and persistent lymphopenia are at risk of prolonged MODS or PICU mortality. This evidence supports testing therapies for pediatric severe sepsis patients risk-stratified by early, persistent lymphopenia.
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Affiliation(s)
- Bradley S Podd
- Division of Pediatric Critical Care Medicine, Department of Critical Care Medicine, Children's Hospital of Pittsburgh, Center for Critical Care Nephrology and Clinical Research Investigation and Systems Modeling of Acute Illness Center, University of Pittsburgh, Pittsburgh, PA
- Department of Pediatrics, University of Pittsburgh, Pittsburgh, PA
| | - Russell K Banks
- Department of Pediatrics, University of Utah, Salt Lake City, UT
| | - Ron Reeder
- Department of Pediatrics, University of Utah, Salt Lake City, UT
| | - Russell Telford
- Department of Statistics, Carnegie Mellon University, Pittsburgh, PA
| | - Richard Holubkov
- Department of Pediatrics, University of Utah, Salt Lake City, UT
| | - Joseph Carcillo
- Division of Pediatric Critical Care Medicine, Department of Critical Care Medicine, Children's Hospital of Pittsburgh, Center for Critical Care Nephrology and Clinical Research Investigation and Systems Modeling of Acute Illness Center, University of Pittsburgh, Pittsburgh, PA
- Department of Pediatrics, University of Pittsburgh, Pittsburgh, PA
| | - Robert A Berg
- Department of Anesthesiology, Children's Hospital of Philadelphia, Philadelphia, PA
| | - David Wessel
- Division of Critical Care Medicine, Department of Pediatrics, Children's National Hospital, Washington, DC
| | - Murray M Pollack
- Division of Critical Care Medicine, Department of Pediatrics, Children's National Hospital, Washington, DC
| | - Kathleen Meert
- Division of Critical Care Medicine, Department of Pediatrics, Children's Hospital of Michigan, Detroit, MI
- Department of Pediatrics, Central Michigan University, Mt. Pleasant, MI
| | - Mark Hall
- Division of Critical Care Medicine, Department of Pediatrics, The Research Institute at Nationwide Children's Hospital Immune Surveillance Laboratory, and Nationwide Children's Hospital, Columbus, OH
| | - Christopher Newth
- Division of Pediatric Critical Care Medicine, Department of Anesthesiology and Pediatrics, Children's Hospital Los Angeles, Los Angeles, CA
| | - John C Lin
- Division of Critical Care Medicine, Department of Pediatrics, St. Louis Children's Hospital, St. Louis, MO
| | - Allan Doctor
- Division of Critical Care Medicine, Department of Pediatrics, St. Louis Children's Hospital, St. Louis, MO
| | - Tom Shanley
- Division of Critical Care Medicine, Department of Pediatrics, C. S. Mott Children's Hospital, Ann Arbor, MI
| | - Tim Cornell
- Division of Critical Care Medicine, Department of Pediatrics, C. S. Mott Children's Hospital, Ann Arbor, MI
| | - Rick E Harrison
- Division of Critical Care Medicine, Department of Pediatrics, Mattel Children's Hospital at University of California Los Angeles, Los Angeles, CA
| | - Athena F Zuppa
- Department of Anesthesiology, Children's Hospital of Philadelphia, Philadelphia, PA
| | - Katherine Sward
- Department of Pediatrics, University of Utah, Salt Lake City, UT
| | - J Michael Dean
- Department of Pediatrics, University of Utah, Salt Lake City, UT
| | - Adrienne G Randolph
- Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital, Boston, MA
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Kahleova H, Holtz DN, Strom N, La Reau A, Kolipaka S, Schmidt N, Hata E, Znayenko-Miller T, Holubkov R, Barnard ND. A dietary intervention for postmenopausal hot flashes: A potential role of gut microbiome. An exploratory analysis. Complement Ther Med 2023; 79:103002. [PMID: 37949415 DOI: 10.1016/j.ctim.2023.103002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2023] [Revised: 10/11/2023] [Accepted: 11/06/2023] [Indexed: 11/12/2023] Open
Abstract
OBJECTIVE This study examined the role of gut microbiome changes in mediating the effects of a dietary intervention on the frequency and severity of postmenopausal vasomotor symptoms METHODS: Postmenopausal women (n = 84) reporting ≥2 moderate-to-severe hot flashes daily were randomly assigned, in 2 successive cohorts, to an intervention including a low-fat, vegan diet and cooked soybeans (½ cup [86 g] daily) or to stay on their usual diet. Over a 12-week period, frequency and severity of hot flashes were recorded with a mobile application. In a subset of 11 women, gut microbiome was analyzed at baseline and after 12 weeks of the dietary intervention (low-fat vegan diet with soybeans), using deep shotgun metagenomic sequencing. Differences in the microbiome between baseline and 12 weeks were assessed by comparing alpha diversity with Wilcoxon signed rank tests, beta diversity with permanovaFL, and taxon abundance with Wilcoxon signed rank tests. Pearson correlations were used to assess the association between changes in hot flashes and gut bacteria. RESULTS In the subset for which microbiome testing was done, total hot flashes decreased by 95 % during the dietary intervention (p = 0.007); severe hot flashes disappeared (from 0.6 to 0.0/day; p = 0.06); and moderate-to-severe hot flashes decreased by 96 % (p = 0.01). Daytime and nighttime hot flashes were reduced by 96 % (p = 0.01) and 94 % (p = 0.004), respectively. Alpha and beta diversity did not significantly differ in the intervention group between baseline and 12 weeks. Two families (Enterobacteriaceae and Veillonellaceae), 5 genera (Erysipelatoclostridium, Fusicatenibacter, Holdemanella, Intestinimonas, and Porphyromonas), and 6 species (Clostridium asparagiforme, Clostridium innocuum, Bacteroides thetaiotaomicron, Fusicatenibacter saccharivorans, Intestinimonas butyriciproducens, Prevotella corporis, and Streptococcus sp.) were differentially abundant, but after correction for multiple comparisons, these differences were no longer significant. Changes in the relative abundance of Porphyromonas and Prevotella corporis were associated with the reduction in severe day hot flashes both unadjusted (r = 0.61; p = 0.047; and r = 0.69; p = 0.02), respectively), and after adjustment for changes in body mass index (r = 0.63; p = 0.049; and r = 0.73; p = 0.02), respectively). Changes in relative abundance of Clostridium asparagiforme were associated with the reduction in total severe hot flashes (r = 0.69; p = 0.019) and severe night hot flashes (r = 0.82; p = 0.002) and the latter association remained significant after adjustment for changes in body mass index (r = 0.75; p = 0.01). CONCLUSIONS This exploratory analysis revealed potential associations between changes in vasomotor symptoms in response to a diet change and changes in the gut microbiome. Larger randomized clinical trials are needed to investigate these findings.
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Affiliation(s)
- Hana Kahleova
- Physicians Committee for Responsible Medicine, Washington, DC, USA.
| | - Danielle N Holtz
- Physicians Committee for Responsible Medicine, Washington, DC, USA
| | | | | | - Sinjana Kolipaka
- Physicians Committee for Responsible Medicine, Washington, DC, USA; Florida Atlantic University, Charles E. Schmidt College of Medicine, FL, USA
| | - Natalie Schmidt
- Physicians Committee for Responsible Medicine, Washington, DC, USA; Florida Atlantic University, Charles E. Schmidt College of Medicine, FL, USA
| | - Ellen Hata
- Physicians Committee for Responsible Medicine, Washington, DC, USA; George Washington University, Milken Institute School of Public Health, DC, USA
| | | | | | - Neal D Barnard
- Physicians Committee for Responsible Medicine, Washington, DC, USA; Adjunct faculty, George Washington University School of Medicine & Health Sciences, Washington, DC, USA
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8
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Cheung C, Kernan KF, Berg RA, Zuppa AF, Notterman DA, Pollack MM, Wessel D, Meert KL, Hall MW, Newth C, Lin JC, Doctor A, Shanley T, Cornell T, Harrison RE, Banks RK, Reeder RW, Holubkov R, Carcillo JA, Fink EL. Acute Disorders of Consciousness in Pediatric Severe Sepsis and Organ Failure: Secondary Analysis of the Multicenter Phenotyping Sepsis-Induced Multiple Organ Failure Study. Pediatr Crit Care Med 2023; 24:840-848. [PMID: 37314247 PMCID: PMC10719421 DOI: 10.1097/pcc.0000000000003300] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Abstract
OBJECTIVES Acute disorders of consciousness (DoC) in pediatric severe sepsis are associated with increased risk of morbidity and mortality. We sought to examine the frequency of and factors associated with DoC in children with sepsis-induced organ failure. DESIGN Secondary analysis of the multicenter Phenotyping Sepsis-Induced Multiple Organ Failure Study (PHENOMS). SETTING Nine tertiary care PICUs in the United States. PATIENTS Children less than 18 years old admitted to a PICU with severe sepsis and at least one organ failure during a PICU stay. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS The primary outcome was frequency of DoC, defined as Glasgow Coma Scale (GCS) less than 12 in the absence of sedatives during an ICU stay, among children with severe sepsis and the following: single organ failure, nonphenotypeable multiple organ failure (MOF), MOF with one of the PHENOMS phenotypes (immunoparalysis-associated MOF [IPMOF], sequential liver failure-associated MOF, thrombocytopenia-associated MOF), or MOF with multiple phenotypes. A multivariable logistic regression analysis was performed to evaluate the association between clinical variables and organ failure groups with DoC. Of 401 children studied, 71 (18%) presented with DoC. Children presenting with DoC were older (median 8 vs 5 yr; p = 0.023), had increased hospital mortality (21% vs 10%; p = 0.011), and more frequently presented with both any MOF (93% vs 71%; p < 0.001) and macrophage activation syndrome (14% vs 4%; p = 0.004). Among children with any MOF, those presenting with DoC most frequently had nonphenotypeable MOF and IPMOF (52% and 34%, respectively). In the multivariable analysis, older age (odds ratio, 1.07; 95% CI, 1.01-1.12) and any MOF (3.22 [1.19-8.70]) were associated with DoC. CONCLUSIONS One of every five children with severe sepsis and organ failure experienced acute DoC during their PICU stay. Preliminary findings suggest the need for prospective evaluation of DoC in children with sepsis and MOF.
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Affiliation(s)
| | - Kate F. Kernan
- Division of Pediatric Critical Care Medicine, UPMC Children’s Hospital of Pittsburgh, Pittsburgh, PA USA
| | - Robert A. Berg
- Department of Anesthesiology and Critical Care Medicine, Children’s Hospital of Philadelphia, Philadelphia, PA, USA
| | - Athena F. Zuppa
- Department of Pediatrics, Children’s Hospital of Philadelphia, Philadelphia, PA, USA
| | | | - Murray M. Pollack
- Department of Pediatrics, Children’s National Hospital, Washington, DC, USA
| | - David Wessel
- Department of Pediatrics, Children’s National Hospital, Washington, DC, USA
| | - Kathleen L. Meert
- Department of Pediatrics, Children’s Hospital of Michigan, Detroit, MI, USA
| | - Mark W. Hall
- Department of Pediatrics, Nationwide Children’s Hospital, Columbus, OH, USA
| | - Christopher Newth
- Division of Pediatric Critical Care Medicine, Department of Anesthesiology and Pediatrics, Children’s Hospital Los Angeles, Los Angeles, CA, USA
| | - John C. Lin
- Division of Critical Care Medicine, Department of Pediatrics, St. Louis Children’s Hospital, St. Louis, MO, USA
| | - Allan Doctor
- Division of Critical Care Medicine, Department of Pediatrics, St. Louis Children’s Hospital, St. Louis, MO, USA
| | - Tom Shanley
- Division of Critical Care Medicine, Department of Pediatrics, C. S. Mott Children’s Hospital, Ann Arbor, MI, USA
| | - Tim Cornell
- Division of Critical Care Medicine, Department of Pediatrics, C. S. Mott Children’s Hospital, Ann Arbor, MI, USA
| | - Rick E. Harrison
- Department of Pediatrics, Mattel Children's Hospital, University of California Los Angeles, Los Angeles, CA, USA
| | | | | | | | - Joseph A. Carcillo
- Division of Pediatric Critical Care Medicine, UPMC Children’s Hospital of Pittsburgh, Pittsburgh, PA USA
| | - Ericka L. Fink
- Division of Pediatric Critical Care Medicine, UPMC Children’s Hospital of Pittsburgh, Pittsburgh, PA USA
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9
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Grissom CK, Holubkov R, Carpenter L, Hanna B, Jacobs JR, Jones C, Knighton AJ, Leither L, Lisonbee D, Peltan ID, Winberg C, Wolfe D, Srivastava R. Implementation of coordinated spontaneous awakening and breathing trials using telehealth-enabled, real-time audit and feedback for clinician adherence (TEACH): a type II hybrid effectiveness-implementation cluster-randomized trial. Implement Sci 2023; 18:45. [PMID: 37735443 PMCID: PMC10515061 DOI: 10.1186/s13012-023-01303-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2023] [Accepted: 09/09/2023] [Indexed: 09/23/2023] Open
Abstract
BACKGROUND Intensive care unit (ICU) patients on mechanical ventilation often require sedation and analgesia to improve comfort and decrease pain. Prolonged sedation and analgesia, however, may increase time on mechanical ventilation, risk for ventilator associated pneumonia, and delirium. Coordinated interruptions in sedation [spontaneous awakening trials (SATs)] and spontaneous breathing trials (SBTs) increase ventilator-free days and improve mortality. Coordination of SATs and SBTs is difficult with substantial implementation barriers due to difficult-to-execute sequencing between nurses and respiratory therapists. Telehealth-enabled remote care has the potential to overcome these barriers and improve coordinated SAT and SBT adherence by enabling proactive high-risk patient monitoring, surveillance, and real-time assistance to frontline ICU teams. METHODS The telehealth-enabled, real-time audit and feedback for clinician adherence (TEACH) study will determine whether adding a telehealth augmented real-time audit and feedback to a usual supervisor-led audit and feedback intervention will yield higher coordinated SAT and SBT adherence and more ventilator-free days in mechanically ventilated patients than a usual supervisor-led audit and feedback intervention alone in a type II hybrid effectiveness-implementation cluster-randomized clinical trial in 12 Intermountain Health hospitals with 15 ICUs. In the active comparator control group (six hospitals), the only intervention is the usual supervisor-led audit and feedback implementation. The telehealth-enabled support (TEACH) intervention in six hospitals adds real-time identification of patients eligible for a coordinated SAT and SBT and consultative input from telehealth respiratory therapists, nurses, and physicians to the bedside clinicians to promote adherence including real-time assistance with execution. All intubated and mechanically ventilated patients ≥ 16 years of age are eligible for enrollment except for patients who die on the day of intubation or have preexisting brain death. Based on preliminary power analyses, we plan a 36-month intervention period that includes a 90-day run-in period. Estimated enrollment in the final analysis is up to 9900 mechanically ventilated patients over 33 months. DISCUSSION The TEACH study will enhance implementation science by providing insight into how a telehealth intervention augmenting a usual audit and feedback implementation may improve adherence to coordinated SAT and SBT and increase ventilator-free days. TRIAL REGISTRATION Clinicaltrials.gov, NCT05141396 , registered 12/02/2021.
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Affiliation(s)
- Colin K Grissom
- Department of Pulmonary and Critical Care Medicine, Intermountain Medical Center, Murray, UT, 84107, USA.
- Division of Pulmonary and Critical Care, Department of Medicine, University of Utah, Salt Lake City, UT, USA.
- Critical Care Operations, Intermountain Health, Canyons Region, Murray, UT, USA.
| | - Richard Holubkov
- Division of Pediatric Critical Care, Department of Pediatrics, University of Utah, Salt Lake City, UT, USA
| | - Lori Carpenter
- Respiratory Care, Intermountain Health, Canyons Region, Salt Lake City, UT, USA
| | - Bridgett Hanna
- Healthcare Delivery Institute, Intermountain Health, Salt Lake City, UT, USA
| | - Jason R Jacobs
- Department of Pulmonary and Critical Care Medicine, Intermountain Medical Center, Murray, UT, 84107, USA
| | - Christopher Jones
- Critical Care Operations, Intermountain Health, Canyons Region, Murray, UT, USA
| | - Andrew J Knighton
- Healthcare Delivery Institute, Intermountain Health, Salt Lake City, UT, USA
| | - Lindsay Leither
- Department of Pulmonary and Critical Care Medicine, Intermountain Medical Center, Murray, UT, 84107, USA
| | - Dee Lisonbee
- Healthcare Delivery Institute, Intermountain Health, Salt Lake City, UT, USA
| | - Ithan D Peltan
- Department of Pulmonary and Critical Care Medicine, Intermountain Medical Center, Murray, UT, 84107, USA
- Division of Pulmonary and Critical Care, Department of Medicine, University of Utah, Salt Lake City, UT, USA
| | - Carrie Winberg
- Respiratory Care, Intermountain Health, Canyons Region, Salt Lake City, UT, USA
| | - Doug Wolfe
- Healthcare Delivery Institute, Intermountain Health, Salt Lake City, UT, USA
| | - Rajendu Srivastava
- Healthcare Delivery Institute, Intermountain Health, Salt Lake City, UT, USA
- Division of Pediatric Hospital Medicine, Department of Pediatrics, University of Utah and Primary Children's Hospital, Salt Lake City, UT, USA
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10
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Kahleova H, Sutton M, Maracine C, Nichols D, Monsivais P, Holubkov R, Barnard ND. Vegan Diet and Food Costs Among Adults With Overweight: A Secondary Analysis of a Randomized Clinical Trial. JAMA Netw Open 2023; 6:e2332106. [PMID: 37669055 PMCID: PMC10481244 DOI: 10.1001/jamanetworkopen.2023.32106] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/26/2023] [Accepted: 07/27/2023] [Indexed: 09/06/2023] Open
Abstract
This secondary analysis of a randomized clinical trial investigates the effects of a vegan diet on total food costs per day.
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Affiliation(s)
- Hana Kahleova
- Physicians Committee for Responsible Medicine, Washington, DC
| | - Macy Sutton
- Physicians Committee for Responsible Medicine, Washington, DC
| | | | | | - Pablo Monsivais
- Department of Nutrition and Exercise Physiology, Elson S. Floyd College of Medicine, Washington State University, Spokane
| | | | - Neal D. Barnard
- Physicians Committee for Responsible Medicine, Washington, DC
- George Washington University School of Medicine and Health Sciences, Washington, DC
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11
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Kahleova H, Znayenko‐Miller T, Uribarri J, Holubkov R, Barnard ND. Dietary advanced glycation products and their associations with insulin sensitivity and body weight: A 16-week randomized clinical trial. Obes Sci Pract 2023; 9:235-242. [PMID: 37287522 PMCID: PMC10242260 DOI: 10.1002/osp4.646] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2022] [Revised: 10/04/2022] [Accepted: 10/10/2022] [Indexed: 06/09/2023] Open
Abstract
Background Evidence suggests that changes in advanced glycation end-products (AGEs) may influence body weight. Previous studies have focused on cooking methods as the primary way how to reduce the dietary AGEs but little is known about the effects of a change in diet composition. Objective The aim of this study was to assess the effects of a low-fat plant-based diet on dietary AGEs and test the association with body weight, body composition, and insulin sensitivity. Methods Participants who were overweight (n = 244) were randomly assigned to an intervention (low-fat plant-based) (n = 122) or control group (n = 122) for 16 weeks. Before and after the intervention period, body composition was measured by dual X-ray absorptiometry. Insulin sensitivity was assessed with the predicted insulin sensitivity index (PREDIM). Three-day diet records were analyzed using the Nutrition Data System for Research software and dietary AGEs were estimated, using a database. Repeated measure ANOVA was used for statistical analysis. Results Dietary AGEs decreased in the intervention group by 8768 ku/day on average (95% -9611 to -7925; p < 0.001), compared with the control group (-1608; 95% CI -2709 to -506; p = 0.005; treatment effect -7161 ku/day [95% CI -8540 to -5781]; Gxt, p < 0.001). Body weight decreased by 6.4 kg in the intervention group, compared with 0.5 kg in the control group (treatment effect -5.9 kg [95% CI -6.8 to -5.0]; Gxt, p < 0.001), largely due to a reduction in fat mass, notably visceral fat. PREDIM increased in the intervention group (treatment effect +0.9 [95% CI + 0.5 to +1.2]; p < 0.001). Changes in dietary AGEs correlated with changes in body weight (r = +0.41; p < 0.001), fat mass (r = +0.38; p < 0.001), visceral fat (r = +0.23; p < 0.001), and PREDIM (r = -0.28; p < 0.001), and remained significant even after adjustment for changes in energy intake (r = +0.35; p < 0.001 for body weight; r = +0.34; p < 0.001 for fat mass; r = +0.15; p = 0.03 for visceral fat; and r = -0.24; p < 0.001 for PREDIM). Conclusions Dietary AGEs decreased on a low-fat plant-based diet, and this decrease was associated with changes in body weight, body composition, and insulin sensitivity, independent of energy intake. These findings demonstrate positive effects of qualitative dietary changes on dietary AGEs and cardiometabolic outcomes. Clinical Trial Registry Number NCT02939638.
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Affiliation(s)
- Hana Kahleova
- Physicians Committee for Responsible MedicineWashingtonDistrict of ColumbiaUSA
| | | | - Jaime Uribarri
- Icahn School of Medicine at Mount SinaiNew YorkNew YorkUSA
| | | | - Neal D. Barnard
- Physicians Committee for Responsible MedicineWashingtonDistrict of ColumbiaUSA
- Adjunct FacultyGeorge Washington University School of Medicine and Health SciencesWashingtonDistrict of ColumbiaUSA
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12
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Dewan MC, Isaacs AM, Cools MJ, Yengo-Kahn A, Naftel RP, Jensen H, Reeder RW, Holubkov R, Haizel-Cobbina J, Riva-Cambrin J, Jafrani RJ, Pindrik JA, Jackson EM, Judy BF, Kurudza E, Pollack IF, Mcdowell MM, Hankinson TC, Staulcup S, Hauptman J, Hall K, Tamber MS, Cheong A, Warsi NM, Rocque BG, Saccomano BW, Snyder RI, Kulkarni AV, Kestle JRW, Wellons JC. Treatment of hydrocephalus following posterior fossa tumor resection: a multicenter collaboration from the Hydrocephalus Clinical Research Network. J Neurooncol 2023; 163:123-132. [PMID: 37129738 DOI: 10.1007/s11060-023-04316-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2023] [Accepted: 04/17/2023] [Indexed: 05/03/2023]
Abstract
OBJECTIVE Persistent hydrocephalus following posterior fossa brain tumor (PFBT) resection is a common cause of morbidity in pediatric brain tumor patients, for which the optimal treatment is debated. The purpose of this study was to compare treatment outcomes between VPS and ETV in patients with persistent hydrocephalus following surgical resection of a PFBT. METHODS A post-hoc analysis was performed of the Hydrocephalus Clinical Research Network (HCRN) prospective observational study evaluating VPS and ETV for pediatric patients. Children who experienced hydrocephalus secondary to PFBT from 2008 to 2021 were included. Primary outcomes were VPS/ETV treatment failure and time-to-failure (TTF). RESULTS Among 241 patients, the VPS (183) and ETV (58) groups were similar in age, extent of tumor resection, and preoperative ETV Success Score. There was no difference in overall treatment failure between VPS and ETV (33.9% vs 31.0%, p = 0.751). However, mean TTF was shorter for ETV than VPS (0.45 years vs 1.30 years, p = 0.001). While major complication profiles were similar, compared to VPS, ETV patients had relatively higher incidence of minor CSF leak (10.3% vs. 1.1%, p = 0.003) and pseudomeningocele (12.1% vs 3.3%, p = 0.02). No ETV failures were identified beyond 3 years, while shunt failures occurred beyond 5 years. Shunt infections occurred in 5.5% of the VPS cohort. CONCLUSIONS ETV and VPS offer similar overall success rates for PFBT-related postoperative hydrocephalus. ETV failure occurs earlier, while susceptibility to VPS failure persists beyond 5 years. Tumor histology and grade may be considered when selecting the optimal means of CSF diversion.
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Affiliation(s)
- Michael C Dewan
- Department of Neurological Surgery, Vanderbilt University Medical Center, Nashville, TN, USA.
- Department of Neurological Surgery, Division of Pediatric Neurological Surgery, Vanderbilt Children's Hospital, 2200 Children's Way, 9226 Doctors Office Tower, Nashville, TN, 37232-9557, USA.
| | - Albert M Isaacs
- Department of Neurological Surgery, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Michael J Cools
- Department of Neurological Surgery, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Aaron Yengo-Kahn
- Department of Neurological Surgery, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Robert P Naftel
- Department of Neurological Surgery, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Hailey Jensen
- Department of Pediatrics, University of Utah, Salt Lake City, UT, USA
| | - Ron W Reeder
- Department of Pediatrics, University of Utah, Salt Lake City, UT, USA
| | - Richard Holubkov
- Department of Pediatrics, University of Utah, Salt Lake City, UT, USA
| | - Joseline Haizel-Cobbina
- Vanderbilt Institute for Global Health, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Jay Riva-Cambrin
- Department of Clinical Neurosciences, University of Calgary, Alberta, Canada
| | - Ryan J Jafrani
- Department of Neurosurgery, St. Louis Children's Hospital, Washington University, St. Louis, MO, USA
| | - Jonathan A Pindrik
- Division of Pediatric Neurosurgery, Department of Neurological Surgery, Nationwide Children's Hospital, The Ohio State University, Columbus, OH, USA
| | - Eric M Jackson
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Brendan F Judy
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Elena Kurudza
- Department of Neurosurgery, University of Utah, Salt Lake City, UT, USA
| | - Ian F Pollack
- Department of Neurosurgery, Children's Hospital of Pittsburgh, University of Pittsburgh, Pittsburgh, PA, USA
| | - Michael M Mcdowell
- Department of Neurosurgery, Children's Hospital of Pittsburgh, University of Pittsburgh, Pittsburgh, PA, USA
| | - Todd C Hankinson
- Department of Neurosurgery, Children's Hospital Colorado, University of Colorado, Aurora, CO, USA
| | - Susan Staulcup
- Department of Neurosurgery, Children's Hospital Colorado, University of Colorado, Aurora, CO, USA
| | - Jason Hauptman
- Department of Neurosurgery, University of Washington, Seattle Children's Hospital, Seattle, WA, USA
| | - Koko Hall
- Department of Neurosurgery, University of Washington, Seattle Children's Hospital, Seattle, WA, USA
| | - Mandeep S Tamber
- Department of Surgery, Division of Neurosurgery, British Columbia Children's Hospital, University of British Columbia, Vancouver, BC, Canada
| | - Alex Cheong
- Department of Surgery, Division of Neurosurgery, British Columbia Children's Hospital, University of British Columbia, Vancouver, BC, Canada
| | - Nebras M Warsi
- Division of Neurosurgery, The Hospital for Sick Children, University of Toronto, Toronto, ON, Canada
| | - Brandon G Rocque
- Division of Pediatric Neurosurgery, Department of Neurosurgery, University of Alabama at Birmingham, Children's of Alabama, Birmingham, AL, USA
| | - Benjamin W Saccomano
- Division of Pediatric Neurosurgery, Department of Neurosurgery, University of Alabama at Birmingham, Children's of Alabama, Birmingham, AL, USA
| | - Rita I Snyder
- Division of Pediatric Neurosurgery, Department of Neurosurgery, Texas Children's Hospital, Baylor College of Medicine, Houston, Texas, USA
| | - Abhaya V Kulkarni
- Division of Neurosurgery, The Hospital for Sick Children, University of Toronto, Toronto, ON, Canada
| | - John R W Kestle
- Department of Neurosurgery, University of Utah, Salt Lake City, UT, USA
| | - John C Wellons
- Department of Neurological Surgery, Vanderbilt University Medical Center, Nashville, TN, USA
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13
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Spivak AM, Barney BJ, Greene T, Holubkov R, Olsen CS, Bridges J, Srivastava R, Webb B, Sebahar F, Huffman A, Pacchia CF, Dean JM, Hess R. A Randomized Clinical Trial Testing Hydroxychloroquine for Reduction of SARS-CoV-2 Viral Shedding and Hospitalization in Early Outpatient COVID-19 Infection. Microbiol Spectr 2023; 11:e0467422. [PMID: 36861976 PMCID: PMC10101001 DOI: 10.1128/spectrum.04674-22] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2022] [Accepted: 02/10/2023] [Indexed: 03/03/2023] Open
Abstract
Early in the COVID-19 pandemic, no effective treatment existed to prevent clinical worsening of COVID-19 among recently diagnosed outpatients. At the University of Utah, Salt Lake City, Utah, we conducted a phase 2 prospective parallel group randomized placebo-controlled trial (NCT04342169) to determine whether hydroxychloroquine given early in disease reduces the duration of SARS-CoV-2 shedding. We enrolled nonhospitalized adults (≥18 years of age) with a recent positive diagnostic test for SARS-CoV-2 (within 72 h of enrollment) and adult household contacts. Participants received either 400 mg hydroxychloroquine by mouth twice daily on day 1 followed by 200 mg by mouth twice daily on days 2 to 5 or oral placebo with the same schedule. We performed SARS-CoV-2 nucleic acid amplification testing (NAAT) on oropharyngeal swabs on days 1 to 14 and 28 and monitored clinical symptomatology, rates of hospitalization, and viral acquisition by adult household contacts. We identified no overall differences in the duration of oropharyngeal carriage of SARS-CoV-2 (hazard ratio of viral shedding time comparing hydroxychloroquine to placebo, 1.21; 95% confidence interval [CI], 0.91, 1.62). Overall, 28-day hospitalization incidence was similar between treatments (4.6% hydroxychloroquine versus 2.7% placebo). No differences were seen in symptom duration, severity, or viral acquisition in household contacts between treatment groups. The study did not reach the prespecified enrollment target, which was likely influenced by a steep decline in COVID-19 incidence corresponding to the initial vaccine rollout in the spring of 2021. Oropharyngeal swabs were self-collected, which may introduce variability in these results. Placebo treatments were not identical to hydroxychloroquine treatments (capsules versus tablets) which may have led to inadvertent participant unblinding. In this group of community adults early in the COVID-19 pandemic, hydroxychloroquine did not significantly alter the natural history of early COVID-19 disease. (This study has been registered at ClinicalTrials.gov under registration no. NCT04342169). IMPORTANCE Early in the COVID-19 pandemic, no effective treatment existed to prevent clinical worsening of COVID-19 among recently diagnosed outpatients. Hydroxychloroquine received attention as a possible early treatment; however, quality prospective studies were lacking. We conducted a clinical trial to test the ability of hydroxychloroquine to prevent clinical worsening of COVID-19.
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Affiliation(s)
- Adam M. Spivak
- Department of Medicine, University of Utah, Salt Lake City, Utah, USA
| | - Bradley J. Barney
- Department of Pediatrics, University of Utah, Salt Lake City, Utah, USA
| | - Tom Greene
- Department of Medicine, University of Utah, Salt Lake City, Utah, USA
- Department of Population Health Sciences, University of Utah, Salt Lake City, Utah, USA
| | - Richard Holubkov
- Department of Pediatrics, University of Utah, Salt Lake City, Utah, USA
| | - Cody S. Olsen
- Department of Pediatrics, University of Utah, Salt Lake City, Utah, USA
| | - Jordan Bridges
- Department of Pediatrics, University of Utah, Salt Lake City, Utah, USA
| | - Raj Srivastava
- Senior Medical Executive Director, Intermountain Healthcare Delivery Institute, Intermountain Healthcare, Salt Lake City, Utah, USA
| | - Brandon Webb
- Division of Infectious Diseases, Intermountain Healthcare, Salt Lake City, Utah, USA
| | - Frances Sebahar
- Department of Pediatrics, University of Utah, Salt Lake City, Utah, USA
| | - Ainsley Huffman
- Utah Clinical and Translational Science Institute, University of Utah, Salt Lake City, Utah, USA
| | | | - J. Michael Dean
- Department of Pediatrics, University of Utah, Salt Lake City, Utah, USA
| | - Rachel Hess
- Department of Medicine, University of Utah, Salt Lake City, Utah, USA
- Department of Population Health Sciences, University of Utah, Salt Lake City, Utah, USA
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14
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Ip CS, Jones DK, Weinlander E, Gudgel B, Lin A, Yazdani H, Pierce J, Holubkov R, Jensen H, Church M, Mifflin MD. Phase I/II randomized, double-masked, placebo-controlled study of processed amniotic fluid drops after PRK. J Cataract Refract Surg 2023; 49:299-304. [PMID: 36730463 DOI: 10.1097/j.jcrs.0000000000001100] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2022] [Accepted: 11/14/2022] [Indexed: 02/04/2023]
Abstract
PURPOSE To evaluate the safety and efficacy of processed amniotic fluid (pAF) used postoperatively after photorefractive keratectomy (PRK). SETTING University of Utah, Moran Eye Center, Salt Lake City, Utah. DESIGN Randomized, double-masked, placebo-controlled prospective study. METHODS 61 participants were randomized to receive either placebo or pAF drops, which were instilled 4 times per day for 1 week after PRK along with routine postoperative medications. The primary outcome measure was time to full re-epithelialization in days. Secondary measures included visual acuity at 30 days and postoperative pain scores during the first week. RESULTS There was no significant difference in time to re-epithelialization, with a median of 5 days for both groups. There were no difference in pain indicator scores during the first week and no difference in corneal staining scores at day 30 between the 2 groups. There were no adverse events. CONCLUSIONS This pilot study evaluating the safety and efficacy of pAF as an additional postoperative topical medication for PRK demonstrated that pAF did not improve the rate of epithelial healing after PRK. pAF may be safely studied in other ocular conditions to determine its effect on epithelial healing.
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Affiliation(s)
- Colin S Ip
- From the Department of Ophthalmology and Visual Sciences, John A. Moran Eye Center, University of Utah, Salt Lake City, Utah (Ip, Jones, Weinlander, Gudgel, Lin, Yazdani, Church, Mifflin); Cell Therapy and Regenerative Medicine, University of Utah, Salt Lake City, Utah (Pierce); Department of Pediatrics, University of Utah, Salt Lake City, Utah (Holubkov, Jensen)
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15
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Kahleova H, Znayenko-Miller T, Uribarri J, Schmidt N, Kolipaka S, Hata E, Holtz DN, Sutton M, Holubkov R, Barnard ND. Dietary advanced glycation end-products and postmenopausal hot flashes: A post-hoc analysis of a 12-week randomized clinical trial. Maturitas 2023; 172:32-38. [PMID: 37084590 DOI: 10.1016/j.maturitas.2023.03.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2022] [Revised: 03/09/2023] [Accepted: 03/20/2023] [Indexed: 03/28/2023]
Abstract
OBJECTIVE Postmenopausal hot flashes are associated with an increased risk of cardiovascular disease and diabetes. Because dietary advanced glycation end-products (AGEs) may act as endocrine disruptors, this study examined the potential association of modifications to the intake of dietary AGEs with the frequency and severity of postmenopausal hot flashes. METHODS Postmenopausal women (n = 84) reporting ≥2 moderate-to-severe hot flashes daily were randomly assigned to either the intervention group or the control group. The former were asked to follow a low-fat, vegan diet, including cooked soybeans (1/2 cup [86 g]/day) for 12 weeks, and the latter continued their usual diets for 12 weeks. Frequency and severity of hot flashes were recorded with a mobile application. Three-day diet records were analyzed using the Nutrition Data System for Research software and dietary AGEs were estimated, using a database. Seventy-one participants completed the whole study and 63 provided complete hot flash and dietary data for the AGEs analysis (n = 31 in the intervention and n = 24 in the control group). Pearson correlations were used to assess the association between changes in hot flashes and dietary AGEs. RESULTS Dietary AGEs decreased in the intervention group by 73 %, that is by 5509 ku/day on average (95 % -7009 to -4009; p < 0.001), compared with the control group (+458; 95 % CI -835 to +1751; p = 0.47; treatment effect -5968 ku/day [95 % CI -7945 to -3991]; Gxt, p < 0.001). Severe hot flashes decreased by 92 % (p < 0.001) and moderate-to-severe hot flashes decreased by 88 % in the intervention group (p < 0.001). Changes in dietary AGEs correlated with changes in severe (r = +0.39; p = 0.002) and moderate hot flashes (r = +0.34; p = 0.009) and remained significant after adjustment for changes in energy intake (r = +0.45; p < 0.001; and r = +0.37; p = 0.004, respectively) and changes in body mass index (r = +0.37; p = 0.004; and r = +0.27; p = 0.04, respectively). The reduction in dietary AGEs required to achieve a predicted reduction in hot flashes by 1/day was 6933 ku/day for severe and 4366 ku/day for moderate-to-severe hot flashes. CONCLUSIONS The reduction in dietary AGEs with a low-fat plant-based diet was associated with a significant reduction in the frequency of severe and moderate-to-severe postmenopausal hot flashes, independent of changes in energy intake and weight loss. Plant-based diets could be used not only to alleviate vasomotor symptoms in postmenopausal women, but also to reduce other health risks associated with AGEs. TRIAL REGISTRATION ClinicalTrials.gov, NCT04587154.
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Luciano M, Holubkov R, Williams MA, Malm J, Nagel S, Moghekar A, Eklund A, Zwimpfer T, Katzen H, Hanley DF, Hamilton MG. Placebo-Controlled Effectiveness of Idiopathic Normal Pressure Hydrocephalus Shunting: A Randomized Pilot Trial. Neurosurgery 2023; 92:481-489. [PMID: 36700738 PMCID: PMC9904195 DOI: 10.1227/neu.0000000000002225] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2022] [Accepted: 09/11/2022] [Indexed: 01/27/2023] Open
Abstract
BACKGROUND Multiple prospective nonrandomized studies have shown 60% to 70% of patients with idiopathic normal pressure hydrocephalus (iNPH) improve with shunt surgery, but multicenter placebo-controlled trial data are necessary to determine its effectiveness. OBJECTIVE To evaluate the effectiveness of cerebrospinal fluid shunting in iNPH through comparison of open vs placebo shunting groups at 4 months using a pilot study. METHODS Patients were randomized to a Codman Certas Plus valve (Integra LifeSciences) set at 4 (open shunt group) or 8 ("virtual off"; placebo group). Patients and assessors were blinded to treatment group. The primary outcome measure was 10-m gait velocity. Secondary outcome measures included functional scales for bladder control, activities of daily living, depression, and quality of life. Immediately after 4-month evaluation, all shunts were adjusted in a blinded fashion to an active setting and followed to 12 months after shunting. RESULTS A total of 18 patients were randomized. At the 4-month evaluation, gait velocity increased by 0.28 ± 0.28 m/s in the open shunt group vs 0.04 ± 0.17 m/s in the placebo group. The estimated treatment difference was 0.22 m/s ([ P = .071], 95% CI -0.02 to 0.46). Overactive Bladder Short Form symptom bother questionnaire significantly improved in open shunt vs placebo ( P = .007). The 4-month treatment delay did not reduce the subsequent response to active shunting, nor did it increase the adverse advents rate at 12 months. CONCLUSION This multicenter, randomized pilot study demonstrates the effectiveness, safety, and feasibility of a placebo-controlled trial in iNPH, and found a trend suggesting gait velocity improves more in the open shunt group than in the placebo group.
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Affiliation(s)
- Mark Luciano
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
- Adult Hydrocephalus Clinical Research Network, Department of Pediatrics, Division of Critical Care, University of Utah School of Medicine, Salt Lake City, Utah, USA
| | - Richard Holubkov
- Adult Hydrocephalus Clinical Research Network, Department of Pediatrics, Division of Critical Care, University of Utah School of Medicine, Salt Lake City, Utah, USA
- Department of Pediatrics, University of Utah School of Medicine, Salt Lake City, Utah, USA
| | - Michael A. Williams
- Adult Hydrocephalus Clinical Research Network, Department of Pediatrics, Division of Critical Care, University of Utah School of Medicine, Salt Lake City, Utah, USA
- Departments of Neurology and Neurological Surgery, University of Washington School of Medicine, Seattle, Washington, USA
| | - Jan Malm
- Department of Clinical Science, Neurosciences, Umeå University, Umeå, Sweden
| | - Sean Nagel
- Adult Hydrocephalus Clinical Research Network, Department of Pediatrics, Division of Critical Care, University of Utah School of Medicine, Salt Lake City, Utah, USA
- Center for Neurological Restoration, Cleveland Clinic, Cleveland, Ohio, USA
- Department of Neurosurgery, Cleveland Clinic, Cleveland, Ohio, USA
| | - Abhay Moghekar
- Adult Hydrocephalus Clinical Research Network, Department of Pediatrics, Division of Critical Care, University of Utah School of Medicine, Salt Lake City, Utah, USA
- Department of Neurology, Johns Hopkins University, Baltimore, Maryland, USA
| | - Anders Eklund
- Department of Radiation Sciences, Biomedical Engineering, Umeå University, Umeå, Sweden
| | - Thomas Zwimpfer
- Adult Hydrocephalus Clinical Research Network, Department of Pediatrics, Division of Critical Care, University of Utah School of Medicine, Salt Lake City, Utah, USA
- Division of Neurosurgery, Department of Surgery, University of British Columbia, Vancouver, Canada
| | - Heather Katzen
- Adult Hydrocephalus Clinical Research Network, Department of Pediatrics, Division of Critical Care, University of Utah School of Medicine, Salt Lake City, Utah, USA
- Department of Neurology, University of Miami Miller School of Medicine, Miami, Florida, USA
| | - Daniel F. Hanley
- Department of Neurology, Johns Hopkins University, Baltimore, Maryland, USA
| | - Mark G. Hamilton
- Adult Hydrocephalus Clinical Research Network, Department of Pediatrics, Division of Critical Care, University of Utah School of Medicine, Salt Lake City, Utah, USA
- Division of Neurosurgery, Department of Clinical Neurosciences, Cumming School of Medicine, University of Calgary, Calgary, Canada
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Muram S, Isaacs AM, Sader N, Holubkov R, Fong A, Conly J, Hamilton MG. A standardized infection prevention bundle for reduction of CSF shunt infections in adult ventriculoperitoneal shunt surgery performed without antibiotic-impregnated catheters. J Neurosurg 2023; 138:494-502. [PMID: 35916085 DOI: 10.3171/2022.5.jns22430] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2022] [Accepted: 05/16/2022] [Indexed: 02/04/2023]
Abstract
OBJECTIVE Ventriculoperitoneal (VP) shunt insertion and revision surgeries are some of the most common procedures that are performed by neurosurgeons. Shunt infections within the adult population are associated with significant morbidity and mortality and rates remain high. The objective of the current study was to use quality improvement (QI) methodology to create a standardized infection prevention bundle aimed at reducing the rate of shunt infections. METHODS A prospective, single-center, single-surgeon QI study was undertaken. Patients were included if they were 18 years of age or older and were undergoing a VP shunt insertion or revision. The primary outcome of the study was the development of a shunt-related surgical site infection, within 1 year of surgery, as defined according to the Canadian Nosocomial Infection Surveillance Program guidelines. There was no standardized protocol prior to July 2013. A bundle coined as the Calgary Adult Shunt Infection Prevention Protocol (CASIPP) was implemented on July 1, 2013, and updated on July 1, 2015, when 2% chlorhexidine gluconate in 70% isopropyl alcohol replaced povidone-iodine for preoperative skin antisepsis. Protocol compliance was regularly monitored using a standardized process. No antibiotic-impregnated catheters were used. RESULTS A total of 621 consecutive VP shunt insertions and revisions were included in the study. The rate of shunt infection was 5.8% during the period in which there was no standardized shunt protocol. After the implementation of the CASIPP the infection rate decreased to 4.0%, and after introduction of the chlorhexidine/alcohol skin antisepsis, the infection rate was 0% in 379 consecutive procedures (p < 0.0001). Multivariable logistic regression analysis demonstrated that the use of chlorhexidine/alcohol with CASIPP was associated with a significant reduction in the odds of developing a shunt infection (OR 0.032, 95% CI 0-0.19, p = 0.0005). CONCLUSIONS The implementation of a standardized shunt infection prevention bundle within the adult population, without the use of antibiotic-impregnated catheters, significantly reduced the rate of shunt infections which was sustained over many years. The use of 2% chlorhexidine gluconate in 70% isopropyl alcohol for preoperative antisepsis may have played a significant role. Multicenter studies should be completed to verify the effectiveness of the authors' protocol.
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Affiliation(s)
- Sandeep Muram
- 1Department of Clinical Neurosciences, Division of Neurosurgery, University of Calgary, Alberta.,2Alberta Health Services, Calgary, Alberta, Canada
| | - Albert M Isaacs
- 1Department of Clinical Neurosciences, Division of Neurosurgery, University of Calgary, Alberta.,2Alberta Health Services, Calgary, Alberta, Canada
| | - Nicholas Sader
- 1Department of Clinical Neurosciences, Division of Neurosurgery, University of Calgary, Alberta.,2Alberta Health Services, Calgary, Alberta, Canada
| | | | - Annie Fong
- 2Alberta Health Services, Calgary, Alberta, Canada.,4Infection Prevention and Control, Alberta Health Services, Calgary
| | - John Conly
- 4Infection Prevention and Control, Alberta Health Services, Calgary.,8O'Brien Institute for Public Health; and
| | - Mark G Hamilton
- 1Department of Clinical Neurosciences, Division of Neurosurgery, University of Calgary, Alberta.,2Alberta Health Services, Calgary, Alberta, Canada.,9The Hotchkiss Brain Institute, University of Calgary, Alberta, Canada
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Horvat CM, Fabio A, Nagin DS, Banks RK, Qin Y, Park HJ, Kernan KF, Canna SW, Berg RA, Wessel D, Pollack MM, Meert K, Hall M, Newth C, Lin JC, Doctor A, Shanley T, Cornell T, Harrison RE, Zuppa AF, Reeder RW, Sward K, Holubkov R, Notterman DA, Dean JM, Carcillo JA. Mortality Risk in Pediatric Sepsis Based on C-reactive Protein and Ferritin Levels. Pediatr Crit Care Med 2022; 23:968-979. [PMID: 36178701 PMCID: PMC9722561 DOI: 10.1097/pcc.0000000000003074] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
OBJECTIVES Interest in using bedside C-reactive protein (CRP) and ferritin levels to identify patients with hyperinflammatory sepsis who might benefit from anti-inflammatory therapies has piqued with the COVID-19 pandemic experience. Our first objective was to identify patterns in CRP and ferritin trajectory among critically ill pediatric sepsis patients. We then examined the association between these different groups of patients in their inflammatory cytokine responses, systemic inflammation, and mortality risks. DATA SOURCES A prospective, observational cohort study. STUDY SELECTION Children with sepsis and organ failure in nine pediatric intensive care units in the United States. DATA EXTRACTION Two hundred and fifty-five children were enrolled. Five distinct clinical multi-trajectory groups were identified. Plasma CRP (mg/dL), ferritin (ng/mL), and 31 cytokine levels were measured at two timepoints during sepsis (median Day 2 and Day 5). Group-based multi-trajectory models (GBMTM) identified groups of children with distinct patterns of CRP and ferritin. DATA SYNTHESIS Group 1 had normal CRP and ferritin levels ( n = 8; 0% mortality); Group 2 had high CRP levels that became normal, with normal ferritin levels throughout ( n = 80; 5% mortality); Group 3 had high ferritin levels alone ( n = 16; 6% mortality); Group 4 had very high CRP levels, and high ferritin levels ( n = 121; 11% mortality); and Group 5 had very high CRP and very high ferritin levels ( n = 30; 40% mortality). Cytokine responses differed across the five groups, with ferritin levels correlated with macrophage inflammatory protein 1α levels and CRP levels reflective of many cytokines. CONCLUSIONS Bedside CRP and ferritin levels can be used together to distinguish groups of children with sepsis who have different systemic inflammation cytokine responses and mortality risks. These data suggest future potential value in personalized clinical trials with specific targets for anti-inflammatory therapies.
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Affiliation(s)
- Christopher M. Horvat
- Division of Pediatric Critical Care Medicine, Department of Critical Care Medicine, UPMC Children’s Hospital of Pittsburgh, University of Pittsburgh, Pittsburgh, PA
| | - Anthony Fabio
- Department of Statistics, Carnegie Mellon University, Pittsburgh, PA
| | - Daniel S. Nagin
- Department of Statistics, Carnegie Mellon University, Pittsburgh, PA
| | | | - Yidi Qin
- Graduate School of Public Health, University of Pittsburgh, Pittsburgh, PA
| | - Hyun-Jung Park
- Graduate School of Public Health, University of Pittsburgh, Pittsburgh, PA
| | - Kate F. Kernan
- Division of Pediatric Critical Care Medicine, Department of Critical Care Medicine, UPMC Children’s Hospital of Pittsburgh, University of Pittsburgh, Pittsburgh, PA
| | - Scott W. Canna
- Department of Pediatrics, University of Pittsburgh, Pittsburgh, PA
| | - Robert A. Berg
- Department of Anesthesiology, Children’s Hospital of Philadelphia, Philadelphia, PA
| | - David Wessel
- Division of Critical Care Medicine, Department of Pediatrics, Children’s National Hospital, Washington, DC
| | - Murray M. Pollack
- Division of Critical Care Medicine, Department of Pediatrics, Children’s National Hospital, Washington, DC
| | - Kathleen Meert
- Division of Critical Care Medicine, Department of Pediatrics, Children’s Hospital of Michigan, Detroit, MI., Central Michigan University, Mt Pleasant MI
| | - Mark Hall
- Division of Critical Care Medicine, Department of Pediatrics, The Research Institute at Nationwide Children’s Hospital Immune Surveillance Laboratory, and Nationwide Children’s Hospital, Columbus, OH
| | - Christopher Newth
- Division of Pediatric Critical Care Medicine, Department of Anesthesiology and Pediatrics, Children’s Hospital Los Angeles, Los Angeles, CA
| | - John C. Lin
- Division of Critical Care Medicine, Department of Pediatrics, St. Louis Children’s Hospital, St. Louis, MO
| | - Allan Doctor
- Division of Critical Care Medicine, Department of Pediatrics, St. Louis Children’s Hospital, St. Louis, MO
| | - Tom Shanley
- Division of Critical Care Medicine, Department of Pediatrics, C. S. Mott Children’s Hospital, Ann Arbor, MI
| | - Tim Cornell
- Division of Critical Care Medicine, Department of Pediatrics, C. S. Mott Children’s Hospital, Ann Arbor, MI
| | - Rick E. Harrison
- Division of Critical Care Medicine, Department of Pediatrics, Mattel Children’s Hospital at University of California Los Angeles, Los Angeles, CA
| | - Athena F. Zuppa
- Department of Anesthesiology, Children’s Hospital of Philadelphia, Philadelphia, PA
| | | | | | | | | | | | - Joseph A. Carcillo
- Division of Pediatric Critical Care Medicine, Department of Critical Care Medicine, UPMC Children’s Hospital of Pittsburgh, University of Pittsburgh, Pittsburgh, PA
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Ward SL, VanBuren JM, Richards R, Holubkov R, Alvey JS, Jensen AR, Pollack MM, Burd RS. Evaluating the association between obesity and discharge functional status after pediatric injury. J Pediatr Surg 2022; 57:598-605. [PMID: 35090717 PMCID: PMC9808528 DOI: 10.1016/j.jpedsurg.2022.01.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/27/2021] [Revised: 12/17/2021] [Accepted: 01/05/2022] [Indexed: 01/29/2023]
Abstract
BACKGROUND Children with obesity frequently have functional impairment after critical illness. Although obesity increases morbidity risk after trauma, the association with functional outcomes in children is unknown. OBJECTIVE To evaluate the association of weight with functional impairment at hospital discharge in children with serious injuries. METHODS This secondary analysis of a multicenter prospective study included children <15 years old with a serious injury. Four weight groups, underweight, healthy weight, overweight, and obesity/severe obesity were defined by body mass index z-scores. The functional status scale (FSS) measured impairment across six functional domains before injury and at hospital discharge. New domain morbidity was defined as a change ≥2 points. The association between weight and functional impairment was determined using logistic regression adjusting for demographics, physiological measures, injury details, presence of a severe head injury, and physical abuse. RESULTS Although most patients discharged with good/unchanged functional status, new domain morbidity occurred in 74 patients (17%). New FSS domain morbidity occurred in 13% of underweight, 14% of healthy weight, 15% of overweight, and 26% of obese/severe obese patients. Compared to healthy weight patients, those with obesity had more frequent new domain morbidity (p = 0.01), while the other weight groups had similar morbidity. However, after adjustment for confounders, weight was not associated with new functional morbidity at discharge. CONCLUSION Patients with obesity have greater frequency of new domain morbidity after a serious injury; however, after accounting for injury characteristics, weight group is not independently associated with new functional morbidity at hospital discharge after injury in children. LEVEL OF EVIDENCE III.
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Affiliation(s)
- Shan L Ward
- Department of Pediatrics, UCSF Benioff Children's Hospitals Oakland, Oakland, CA, United States; Department of Pediatrics, UCSF Benioff Children's Hospitals San Francisco, San Francisco, CA, United States.
| | - John M VanBuren
- Department of Pediatrics, University of Utah School of Medicine, Salt Lake City, UT, United States
| | - Rachel Richards
- Department of Pediatrics, University of Utah School of Medicine, Salt Lake City, UT, United States
| | - Richard Holubkov
- Department of Pediatrics, University of Utah School of Medicine, Salt Lake City, UT, United States
| | - Jessica S Alvey
- Department of Pediatrics, University of Utah School of Medicine, Salt Lake City, UT, United States
| | - Aaron R Jensen
- Department of Surgery, University of California San Francisco and Division of Pediatric Surgery, UCSF Benioff Children's Hospital Oakland, Oakland, CA, United States
| | - Murray M Pollack
- Department of Pediatrics, Children's National Health System and the George Washington University School of Medicine and Health Sciences, Washington DC, United States
| | - Randall S Burd
- Division of Trauma and Burn Surgery, Children's National Medical Center, Washington, DC, United States; Eunice Kennedy Shriver National Institute of Child Health and Human Development Collaborative Pediatric Critical Care Research Network (CPCCRN) Assessment of Health-Related Quality of Life and Functional Outcomes after Pediatric Trauma Project Investigators
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Maddux AB, VanBuren JM, Jensen AR, Holubkov R, Alvey JS, McQuillen P, Mourani PM, Meert KL, Burd RS. Post-discharge rehabilitation and functional recovery after pediatric injury. Injury 2022; 53:2795-2803. [PMID: 35680434 PMCID: PMC9808527 DOI: 10.1016/j.injury.2022.05.023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/21/2022] [Accepted: 05/15/2022] [Indexed: 02/02/2023]
Abstract
INTRODUCTION Variability in rehabilitation disposition has been proposed as a trauma center quality metric. Benchmarking rehabilitation disposition is limited by a lack of objective measures of functional impairment at discharge. The primary aim of this study was to determine the relative contribution of patient characteristics and hospitalization factors associated with inpatient and outpatient rehabilitation after discharge. The secondary aims were to evaluate the sensitivity of the Functional Status Scale (FSS) score for identifying functional impairments at hospital discharge and track post-discharge recovery. PATIENTS AND METHODS We report a planned secondary analysis of a prospective observational study of seriously injured children (<15 years old) enrolled at seven pediatric trauma centers. Functional Status Scale (FSS) score was measured for pre-injury, hospital discharge, and 6-month follow-up timepoints. Multinomial logistic regression identified factors associated with three dispositions: home without rehabilitation services, home with outpatient rehabilitation, and inpatient rehabilitation. Relative weight analysis was used to identify the impact of individual factors associated with inpatient or outpatient rehabilitation disposition. RESULTS We analyzed 427 children with serious injuries. Functional impairment at discharge was present in 103 (24.1%) children, including 43/337 (12.8%) discharged without services, 12/38 (31.6%) discharged with outpatient rehabilitation, and 44/47 (93.6%) discharged to inpatient rehabilitation. In multivariable modeling, variables most contributing to prediction of inpatient rehabilitation were severe initial Glasgow coma scale (GCS), injured body region, and functional impairment at discharge. Severe initial GCS, private insurance, and extremity injury were independently associated with disposition with outpatient rehabilitation. Patients discharged without services or with outpatient rehabilitation most frequently had motor impairments that improved during the next 6 months. Patients discharged to inpatient rehabilitation had impairments in all domains, with many improving within 6 months. A higher proportion of patients discharged to inpatient rehabilitation had residual impairments at follow-up. CONCLUSION Injury characteristics and discharge impairment were associated with discharge to inpatient rehabilitation. The FSS score identified impairments needing inpatient rehabilitation and characterized improvements after discharge. Less severe impairments needing outpatient rehabilitation were not identified by the FSS score.
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Affiliation(s)
- Aline B. Maddux
- Department of Pediatrics, Section of Critical Care Medicine, University of Colorado School of Medicine and Children’s Hospital Colorado, 13121 E 17th Ave, MS 8414, Aurora, CO, 80045, United States,Corresponding author at: Pediatric Critical Care, University of Colorado School of Medicine, Children’s Hospital Colorado, Education 2 South, 13121 East 17th Avenue, MS 8414, Aurora, CO 80045. (A.B. Maddux)
| | - John M. VanBuren
- Department of Pediatrics, University of Utah School of Medicine, 295 Chipeta Way, Salt Lake City, UT, 84108, United States
| | - Aaron R. Jensen
- Department of Surgery, University of California San Francisco and UCSF Benioff Children’s Hospital, 1411 East 31st St, Oakland, CA, 94602, United States
| | - Richard Holubkov
- Department of Pediatrics, University of Utah School of Medicine, 295 Chipeta Way, Salt Lake City, UT, 84108, United States
| | - Jessica S. Alvey
- Department of Pediatrics, University of Utah School of Medicine, 295 Chipeta Way, Salt Lake City, UT, 84108, United States
| | - Patrick McQuillen
- Department of Pediatrics, Benioff Children’s Hospital, University of California, San Francisco, 1550 Fourth St, San Francisco, CA, 94158, United States
| | - Peter M. Mourani
- Department of Pediatrics, Section of Critical Care Medicine, University of Colorado School of Medicine and Children’s Hospital Colorado, 13121 E 17th Ave, MS 8414, Aurora, CO, 80045, United States,Department of Pediatrics, Section of Critical Care, Arkansas Children’s, 13 Children’s Way, Slot 842, Little Rock, AR, 72202, United States
| | - Kathleen L Meert
- Department of Pediatrics, Children’s Hospital of Michigan, Central Michigan University, 3901 Beaubien, Detroit, MI, 48201, United States
| | - Randall S. Burd
- Division of Trauma and Burn Surgery, Children’s National Hospital, 111 Michigan Avenue NW, Washington, DC 20010, United States
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Ames SG, Banks RK, Zinter MS, Fink EL, McQuillen PS, Hall MW, Zuppa A, Meert KL, Mourani PM, Carcillo JA, Carpenter T, Pollack MM, Berg RA, Mareboina M, Holubkov R, Dean JM, Notterman DA, Sapru A. Assessment of Patient Health-Related Quality of Life and Functional Outcomes in Pediatric Acute Respiratory Distress Syndrome. Pediatr Crit Care Med 2022; 23:e319-e328. [PMID: 35452018 DOI: 10.1097/pcc.0000000000002959] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
OBJECTIVES To describe health-related quality of life (HRQL) and functional outcomes in pediatric acute respiratory distress syndrome (ARDS) and to determine risk factors associated with poor outcome defined as death or severe reduction in HRQL at 28 days or ICU discharge. DESIGN Prospective multisite cohort-outcome study conducted between 2019 and 2020. SETTING Eight academic PICUs in the United States. PATIENTS Children with ARDS based on standard criteria. INTERVENTIONS Patient characteristics and illness severity were collected during PICU admission. Parent proxy-report measurements were obtained at baseline, day 28/ICU discharge, month 3, and month 9, utilizing Pediatric Quality of Life Inventory and Functional Status Scale (FSS). A composite outcome evaluated using univariate and multivariate analysis was death or severe reduction in HRQL (>25% reduction in the Pediatric Quality of Life Inventory at day 28/ICU discharge. MEASUREMENTS AND MAIN RESULTS This study enrolled 122 patients with a median age of 3 years (interquartile range, 1-12 yr). Common etiologies of ARDS included pneumonia ( n = 63; 52%) and sepsis ( n = 27; 22%). At day 28/ICU discharge, half (50/95; 53%) of surviving patients with follow-up data reported a greater than 10% decrease in HRQL from baseline, and approximately one-third of participants ( n = 19/61; 31%) reported a greater than 10% decrease in HRQL at 9 months. Trends in FSS were similar. Of 104 patients with data, 47 patients (45%) died or reported a severe decrease of greater than 25% in HRQL at day 28/ICU discharge. Older age was associated with an increased risk of death or severe reduction in HRQL (odds ratio, 1.08; CI, 1.01-1.16). CONCLUSIONS Children with ARDS are at risk for deterioration in HRQL and FSS that persists up to 9 months after ARDS. Almost half of children with ARDS experience a poor outcome including death or severe reduction in HRQL at day 28/ICU discharge.
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Affiliation(s)
| | | | - Matt S Zinter
- Benioff Children's Hospital, University of California-San Francisco, San Francisco, CA
| | - Ericka L Fink
- Children's Hospital of Pittsburgh, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Patrick S McQuillen
- Benioff Children's Hospital, University of California-San Francisco, San Francisco, CA
| | - Mark W Hall
- Nationwide Children's Hospital, Columbus, OH
| | - Athena Zuppa
- Children's Hospital of Philadelphia, Philadelphia, PA
| | | | | | - Joseph A Carcillo
- Children's Hospital of Pittsburgh, University of Pittsburgh Medical Center, Pittsburgh, PA
| | | | | | - Robert A Berg
- Children's Hospital of Philadelphia, Philadelphia, PA
| | - Manvita Mareboina
- Mattel Children's Hospital, University of California-Los Angeles, Los Angeles, CA
| | | | | | | | - Anil Sapru
- Mattel Children's Hospital, University of California-Los Angeles, Los Angeles, CA
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Qin Y, Kernan KF, Fan Z, Park HJ, Kim S, Canna SW, Kellum JA, Berg RA, Wessel D, Pollack MM, Meert K, Hall M, Newth C, Lin JC, Doctor A, Shanley T, Cornell T, Harrison RE, Zuppa AF, Banks R, Reeder RW, Holubkov R, Notterman DA, Michael Dean J, Carcillo JA. Machine learning derivation of four computable 24-h pediatric sepsis phenotypes to facilitate enrollment in early personalized anti-inflammatory clinical trials. Crit Care 2022; 26:128. [PMID: 35526000 PMCID: PMC9077858 DOI: 10.1186/s13054-022-03977-3] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2021] [Accepted: 04/03/2022] [Indexed: 12/16/2022] Open
Abstract
BACKGROUND Thrombotic microangiopathy-induced thrombocytopenia-associated multiple organ failure and hyperinflammatory macrophage activation syndrome are important causes of late pediatric sepsis mortality that are often missed or have delayed diagnosis. The National Institutes of General Medical Science sepsis research working group recommendations call for application of new research approaches in extant clinical data sets to improve efficiency of early trials of new sepsis therapies. Our objective is to apply machine learning approaches to derive computable 24-h sepsis phenotypes to facilitate personalized enrollment in early anti-inflammatory trials targeting these conditions. METHODS We applied consensus, k-means clustering analysis to our extant PHENOtyping sepsis-induced Multiple organ failure Study (PHENOMS) dataset of 404 children. 24-hour computable phenotypes are derived using 25 available bedside variables including C-reactive protein and ferritin. RESULTS Four computable phenotypes (PedSep-A, B, C, and D) are derived. Compared to all other phenotypes, PedSep-A patients (n = 135; 2% mortality) were younger and previously healthy, with the lowest C-reactive protein and ferritin levels, the highest lymphocyte and platelet counts, highest heart rate, and lowest creatinine (p < 0.05); PedSep-B patients (n = 102; 12% mortality) were most likely to be intubated and had the lowest Glasgow Coma Scale Score (p < 0.05); PedSep-C patients (n = 110; mortality 10%) had the highest temperature and Glasgow Coma Scale Score, least pulmonary failure, and lowest lymphocyte counts (p < 0.05); and PedSep-D patients (n = 56, 34% mortality) had the highest creatinine and number of organ failures, including renal, hepatic, and hematologic organ failure, with the lowest platelet counts (p < 0.05). PedSep-D had the highest likelihood of developing thrombocytopenia-associated multiple organ failure (Adj OR 47.51 95% CI [18.83-136.83], p < 0.0001) and macrophage activation syndrome (Adj OR 38.63 95% CI [13.26-137.75], p < 0.0001). CONCLUSIONS Four computable phenotypes are derived, with PedSep-D being optimal for enrollment in early personalized anti-inflammatory trials targeting thrombocytopenia-associated multiple organ failure and macrophage activation syndrome in pediatric sepsis. A computer tool for identification of individual patient membership ( www.pedsepsis.pitt.edu ) is provided. Reproducibility will be assessed at completion of two ongoing pediatric sepsis studies.
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Affiliation(s)
- Yidi Qin
- Graduate School of Public Health, University of Pittsburgh, Pittsburgh, PA, USA
| | - Kate F Kernan
- Division of Pediatric Critical Care Medicine, Department of Critical Care Medicine, Children's Hospital of Pittsburgh, Center for Critical Care Nephrology and Clinical Research Investigation and Systems Modeling of Acute Illness Center, Faculty Pavilion, UPMC Children's Hospital of Pittsburgh, University of Pittsburgh, Suite 2000, 4400 Penn Avenue, Pittsburgh, PA, 15421, USA
| | - Zhenjiang Fan
- Department of Computer Sciences, University of Pittsburgh, Pittsburgh, PA, USA
| | - Hyun-Jung Park
- Graduate School of Public Health, University of Pittsburgh, Pittsburgh, PA, USA
| | - Soyeon Kim
- Department of Pediatrics, University of Pittsburgh, Pittsburgh, PA, USA
| | - Scott W Canna
- Department of Pediatrics, University of Pittsburgh, Pittsburgh, PA, USA
| | - John A Kellum
- Division of Pediatric Critical Care Medicine, Department of Critical Care Medicine, Children's Hospital of Pittsburgh, Center for Critical Care Nephrology and Clinical Research Investigation and Systems Modeling of Acute Illness Center, Faculty Pavilion, UPMC Children's Hospital of Pittsburgh, University of Pittsburgh, Suite 2000, 4400 Penn Avenue, Pittsburgh, PA, 15421, USA
| | - Robert A Berg
- Department of Anesthesiology, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - David Wessel
- Division of Critical Care Medicine, Department of Pediatrics, Children's National Hospital, Washington, DC, USA
| | - Murray M Pollack
- Division of Critical Care Medicine, Department of Pediatrics, Children's National Hospital, Washington, DC, USA
| | - Kathleen Meert
- Division of Critical Care Medicine, Department of Pediatrics, Children's Hospital of Michigan, Detroit, MI, USA
- Central Michigan University, Mt. Pleasant, MI, USA
| | - Mark Hall
- Division of Critical Care Medicine, Department of Pediatrics, The Research Institute at Nationwide Children's Hospital Immune Surveillance Laboratory, and Nationwide Children's Hospital, Columbus, OH, USA
| | - Christopher Newth
- Division of Critical Care Medicine, Department of Anesthesiology and Critical Care Medicine, Children's Hospital Los Angeles, Los Angeles, CA, USA
| | - John C Lin
- Division of Critical Care Medicine, Department of Pediatrics, St. Louis Children's Hospital, St. Louis, MO, USA
| | - Allan Doctor
- Division of Critical Care Medicine, Department of Pediatrics, St. Louis Children's Hospital, St. Louis, MO, USA
| | - Tom Shanley
- Division of Critical Care Medicine, Department of Pediatrics, Mattel Children's Hospital at University of California Los Angeles, Los Angeles, CA, USA
| | | | - Rick E Harrison
- Division of Critical Care Medicine, Department of Pediatrics, C. S. Mott Children's Hospital, Ann Arbor, MI, USA
| | - Athena F Zuppa
- Department of Pediatrics, University of Pittsburgh, Pittsburgh, PA, USA
| | - Russell Banks
- Division of Critical Care Medicine, Department of Pediatrics, Mattel Children's Hospital at University of California Los Angeles, Los Angeles, CA, USA
| | - Ron W Reeder
- Division of Critical Care Medicine, Department of Pediatrics, Mattel Children's Hospital at University of California Los Angeles, Los Angeles, CA, USA
| | - Richard Holubkov
- Division of Critical Care Medicine, Department of Pediatrics, Mattel Children's Hospital at University of California Los Angeles, Los Angeles, CA, USA
| | - Daniel A Notterman
- University of Utah, Salt Lake City, UT, USA
- Princeton University, Princeton, NJ, USA
| | - J Michael Dean
- Division of Critical Care Medicine, Department of Pediatrics, Mattel Children's Hospital at University of California Los Angeles, Los Angeles, CA, USA
| | - Joseph A Carcillo
- Division of Pediatric Critical Care Medicine, Department of Critical Care Medicine, Children's Hospital of Pittsburgh, Center for Critical Care Nephrology and Clinical Research Investigation and Systems Modeling of Acute Illness Center, Faculty Pavilion, UPMC Children's Hospital of Pittsburgh, University of Pittsburgh, Suite 2000, 4400 Penn Avenue, Pittsburgh, PA, 15421, USA.
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23
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Barnard ND, Levin S, Crosby L, Flores R, Holubkov R, Kahleova H. A Randomized, Crossover Trial of a Nutritional Intervention for Rheumatoid Arthritis. Am J Lifestyle Med 2022. [DOI: 10.1177/15598276221081819] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
To investigate the effects of a dietary intervention on arthritis pain and disease severity, 44 adults previously diagnosed with rheumatoid arthritis were randomly assigned to a Diet phase (vegan diet for 4 weeks, elimination of additional foods for 3 weeks, and then reintroduction of the eliminated foods individually over 9 weeks) or a Supplement (placebo) phase for 16 weeks. After a 4-week washout, they then switched to the opposite phase. The Disease Activity Score-28 (DAS28) decreased from 4.5 to 2.5 (P < .001) in the Diet phase and from 3.2 to 2.9 (P = .41) in the Supplement phase (between-group P = .01). The mean number of swollen joints decreased from 7.0 to 3.3 in the Diet phase (P = .03) and increased from 4.7 to 5 in the Supplement phase (P = .63; between-group P = .047). In a subanalysis excluding individuals who increased medications during the study, DAS28 decreased 1.9 points in the Diet phase (P = .003) and .4 points in the Supplement phase (P = .27; between-group P = .04). In a further subanalysis limited to participants making no medication changes, DAS28 decreased 1.5 points in the Diet phase (P = .009) and .3 points in the Supplement phase (P = .40, between-group P = .11). We conclude that the dietary intervention was associated with symptomatic improvements. TRIAL REGISTRATION: Clinicaltrials.gov NCT01544101, NCT01700881, NCT03417648, and NCT03580681
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Affiliation(s)
- Neal D. Barnard
- George Washington University School of Medicine & Health Science; Physicians Committee for Responsible Medicine, Washington, DC, USA
| | - Susan Levin
- Physicians Committee for Responsible Medicine, Washington, DC, USA
| | - Lee Crosby
- Physicians Committee for Responsible Medicine, Washington, DC, USA
| | - Rosendo Flores
- Physicians Committee for Responsible Medicine, Washington, DC, USA
| | | | - Hana Kahleova
- Physicians Committee for Responsible Medicine, Washington, DC, USA
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24
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Yates AR, Berger JT, Reeder RW, Banks R, Mourani PM, Berg RA, Carcillo JA, Carpenter T, Hall MW, Meert KL, McQuillen PS, Pollack MM, Sapru A, Notterman DA, Holubkov R, Dean JM, Wessel DL. Characterization of Inhaled Nitric Oxide Use for Cardiac Indications in Pediatric Patients. Pediatr Crit Care Med 2022; 23:245-254. [PMID: 35200229 PMCID: PMC9058189 DOI: 10.1097/pcc.0000000000002917] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES Characterize the use of inhaled nitric oxide (iNO) for pediatric cardiac patients and assess the relationship between patient characteristics before iNO initiation and outcomes following cardiac surgery. DESIGN Observational cohort study. SETTING PICU and cardiac ICUs in seven Collaborative Pediatric Critical Care Research Network hospitals. PATIENTS Consecutive patients, less than 18 years old, mechanically ventilated before or within 24 hours of iNO initiation. iNO was started for a cardiac indication and excluded newborns with congenital diaphragmatic hernia, meconium aspiration syndrome, and persistent pulmonary hypertension, or when iNO started at an outside institution. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Four-hundred seven patients with iNO initiation based on cardiac dysfunction. Cardiac dysfunction patients were administered iNO for a median of 4 days (2-7 d). There was significant morbidity with 51 of 407 (13%) requiring extracorporeal membrane oxygenation and 27 of 407 (7%) requiring renal replacement therapy after iNO initiation, and a 28-day mortality of 46 of 407 (11%). Of the 366 (90%) survivors, 64 of 366 patients (17%) had new morbidity as assessed by Functional Status Scale. Among the postoperative cardiac surgical group (n = 301), 37 of 301 (12%) had a superior cavopulmonary connection and nine of 301 (3%) had a Fontan procedure. Based on echocardiographic variables prior to iNO (n = 160) in the postoperative surgical group, right ventricle dysfunction was associated with 28-day and hospital mortalities (both, p < 0.001) and ventilator-free days (p = 0.003); tricuspid valve regurgitation was only associated with ventilator-free days (p < 0.001), whereas pulmonary hypertension was not associated with mortality or ventilator-free days. CONCLUSIONS Pediatric patients in whom iNO was initiated for a cardiac indication had a high mortality rate and significant morbidity. Right ventricular dysfunction, but not the presence of pulmonary hypertension on echocardiogram, was associated with ventilator-free days and mortality.
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Affiliation(s)
- Andrew R. Yates
- Nationwide Children’s Hospital, The Ohio State University, Columbus, OH
| | | | | | | | - Peter M. Mourani
- Children’s Hospital Colorado, University of Colorado School of Medicine, Aurora, CO
| | - Robert A. Berg
- The Children’s Hospital of Philadelphia, Philadelphia, PA
| | | | - Todd Carpenter
- Children’s Hospital Colorado, University of Colorado School of Medicine, Aurora, CO
| | - Mark W. Hall
- Nationwide Children’s Hospital, The Ohio State University, Columbus, OH
| | - Kathleen L. Meert
- Children’s Hospital of Michigan, Detroit, Michigan; Central Michigan University, Mt. Pleasant, MI
| | | | | | - Anil Sapru
- Mattel Children’s Hospital, Los Angeles, CA
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25
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Evans LL, Jensen AR, Meert KL, VanBuren JM, Richards R, Alvey JS, Carcillo JA, McQuillen PS, Mourani PM, Nance ML, Holubkov R, Pollack MM, Burd RS. All body region injuries are not equal: Differences in pediatric discharge functional status based on Abbreviated Injury Scale (AIS) body regions and severity scores. J Pediatr Surg 2022; 57:739-746. [PMID: 35090715 DOI: 10.1016/j.jpedsurg.2021.09.052] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/22/2021] [Accepted: 09/27/2021] [Indexed: 10/20/2022]
Abstract
PURPOSE Functional outcomes have been proposed for assessing quality of pediatric trauma care. Outcomes assessments often rely on Abbreviated Injury Scale (AIS) severity scores to adjust for injury characteristics, but the relationship between AIS severity and functional impairment is unknown. This study's primary aim was to quantify functional impairment associated with increasing AIS severity scores within body regions. The secondary aim was to assess differences in impairment between body regions based on AIS severity. METHODS Children with serious (AIS≥ 3) isolated body region injuries enrolled in a multicenter prospective study were analyzed. The primary outcome was functional status at discharge measured using the Functional Status Scale (FSS). Discharge FSS was compared (1) within each body region across increasing AIS severity scores, and (2) between body regions for injuries with matching AIS scores. RESULTS The study included 266 children, with 16% having abnormal FSS at discharge. Worse FSS was associated with increasing AIS severity only for spine injuries. Abnormal FSS was observed in a greater proportion of head injury patients with a severely impaired initial Glasgow Coma Scale (GCS) (GCS< 9) compared to those with a higher GCS score (43% versus 9%; p < 0.01). Patients with AIS 3 extremity and severe head injuries had a higher proportion of abnormal FSS at discharge than AIS 3 abdomen or non-severe head injuries. CONCLUSIONS AIS severity does not account for variability in discharge functional impairment within or between body regions. Benchmarking based on functional status assessment requires clinical factors in addition to AIS severity for appropriate risk adjustment. LEVEL OF EVIDENCE 1 (Prognostic and Epidemiological).
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Affiliation(s)
- Lauren L Evans
- Department of Surgery, Division of Pediatric Surgery, UCSF Benioff Children's Hospital Oakland, 744 52nd Street, 4th Floor OPC2, Oakland CA 94609, United States
| | - Aaron R Jensen
- Department of Surgery, Division of Pediatric Surgery, UCSF Benioff Children's Hospital Oakland, 744 52nd Street, 4th Floor OPC2, Oakland CA 94609, United States.
| | - Kathleen L Meert
- Department of Pediatrics, Children's Hospital of Michigan, Central Michigan University, Detroit, MI 48201, United States
| | - John M VanBuren
- Department of Pediatrics, University of Utah School of Medicine, Salt Lake City, UT 84108, United States
| | - Rachel Richards
- Department of Pediatrics, University of Utah School of Medicine, Salt Lake City, UT 84108, United States
| | - Jessica S Alvey
- Department of Pediatrics, University of Utah School of Medicine, Salt Lake City, UT 84108, United States
| | - Joseph A Carcillo
- Department of Critical Care Medicine and Pediatrics, Children's Hospital of Pittsburgh, Pittsburgh, PA
| | - Patrick S McQuillen
- Department of Pediatrics, Benioff Children's Hospital, University of California San Francisco, San Francisco, CA
| | - Peter M Mourani
- Department of Pediatrics, Children's Hospital Colorado and University of Colorado School of Medicine, Aurora, CO
| | - Michael L Nance
- Division of Pediatric Surgery, Department of Surgery, Perelman School of Medicine at the University of Pennsylvania, Children's Hospital of Philadelphia, Philadelphia, PA
| | - Richard Holubkov
- Department of Pediatrics, University of Utah School of Medicine, Salt Lake City, UT 84108, United States
| | - Murray M Pollack
- Department of Pediatrics, Children's National Health System and the George Washington University School of Medicine and Health Sciences, Washington DC 20010, United States
| | - Randall S Burd
- Division of Trauma and Burn Surgery, Children's National Medical Center, Washington, DC 20010, United States
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26
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Chu J, Jensen H, Holubkov R, Krieger MD, Kulkarni AV, Riva-Cambrin J, Rozzelle CJ, Limbrick DD, Wellons JC, Browd SR, Whitehead WE, Pollack IF, Simon TD, Tamber MS, Hauptman JS, Pindrik J, Naftel RP, McDonald PJ, Hankinson TC, Jackson EM, Rocque BG, Reeder R, Drake JM, Kestle JRW. The Hydrocephalus Clinical Research Network quality improvement initiative: the role of antibiotic-impregnated catheters and vancomycin wound irrigation. J Neurosurg Pediatr 2022:1-8. [PMID: 35303708 DOI: 10.3171/2022.2.peds2214] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/12/2022] [Accepted: 02/02/2022] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Two previous Hydrocephalus Clinical Research Network (HCRN) studies have demonstrated that compliance with a standardized CSF shunt infection protocol reduces shunt infections. In this third iteration, a simplified protocol consisting of 5 steps was implemented. This analysis provides an updated evaluation of protocol compliance and evaluates modifiable shunt infection risk factors. METHODS The new simplified protocol was implemented at HCRN centers on November 1, 2016, for all shunt procedures, excluding external ventricular drains, ventricular reservoirs, and subgaleal shunts. Procedures performed through December 31, 2019, were included (38 months). Compliance with the protocol, use of antibiotic-impregnated catheters (AICs), and other variables of interest were collected at the index operation. Outcome events for a minimum of 6 months postoperatively were recorded. The definition of infection was unchanged from the authors' previous report. RESULTS A total of 4913 procedures were performed at 13 HCRN centers. The overall infection rate was 5.1%. Surgeons were compliant with all 5 steps of the protocol in 79.4% of procedures. The infection rate for the protocol alone was 8.1% and dropped to 4.9% when AICs were added. Multivariate analysis identified having ≥ 2 complex chronic conditions (odds ratio [OR] 1.76, 95% confidence interval [CI] 1.26-2.44, p = 0.01) and a history of prior shunt surgery within 12 weeks (OR 1.84, 95% CI 1.37-2.47, p < 0.01) as independent risk factors for shunt infection. The use of AICs (OR 0.70, 95% CI 0.50-0.97, p = 0.05) and vancomycin irrigation (OR 0.36, 95% CI 0.21-0.62, p < 0.01) were identified as independent factors protective against shunt infection. CONCLUSIONS The authors report the third iteration of their quality improvement protocol to reduce the risk of shunt infection. Compliance with the protocol was high. These updated data suggest that the incorporation of AICs is an important, modifiable infection prevention measure. Vancomycin irrigation was also identified as a protective factor but requires further study to better understand its role in preventing shunt infection.
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Affiliation(s)
- Jason Chu
- 1Division of Neurosurgery, Children's Hospital Los Angeles, Department of Neurosurgery, University of Southern California, Los Angeles, California
| | - Hailey Jensen
- 2Department of Pediatrics, University of Utah, Salt Lake City, Utah
| | - Richard Holubkov
- 2Department of Pediatrics, University of Utah, Salt Lake City, Utah
| | - Mark D Krieger
- 1Division of Neurosurgery, Children's Hospital Los Angeles, Department of Neurosurgery, University of Southern California, Los Angeles, California
| | - Abhaya V Kulkarni
- 3Division of Neurosurgery, Hospital for Sick Children, University of Toronto, Ontario, Canada
| | - Jay Riva-Cambrin
- 4Department of Clinical Neurosciences, University of Calgary, Alberta, Canada
| | - Curtis J Rozzelle
- 5Section of Pediatric Neurosurgery, Division of Neurosurgery, Children's Hospital of Alabama, University of Alabama-Birmingham, Alabama
| | - David D Limbrick
- 6Department of Neurosurgery, St. Louis Children's Hospital, Washington University in St. Louis, Missouri
| | - John C Wellons
- 7Division of Pediatric Neurosurgery, Department of Neurological Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Samuel R Browd
- 8Department of Neurosurgery, University of Washington, Seattle Children's Hospital, Seattle, Washington
| | - William E Whitehead
- 9Division of Pediatric Neurosurgery, Department of Neurosurgery, Texas Children's Hospital, Baylor College of Medicine, Houston, Texas
| | - Ian F Pollack
- 10Division of Neurosurgery, Children's Hospital of Pittsburgh, Pennsylvania
| | - Tamara D Simon
- 11Department of Pediatrics, Children's Hospital Los Angeles, University of Southern California, Los Angeles, California
| | - Mandeep S Tamber
- 12Department of Surgery, Division of Neurosurgery, British Columbia Children's Hospital, University of British Columbia, Vancouver, British Columbia, Canada
| | - Jason S Hauptman
- 8Department of Neurosurgery, University of Washington, Seattle Children's Hospital, Seattle, Washington
| | - Jonathan Pindrik
- 13Department of Neurosurgery, Nationwide Children's Hospital, Columbus, Ohio
| | - Robert P Naftel
- 7Division of Pediatric Neurosurgery, Department of Neurological Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Patrick J McDonald
- 14Section of Neurosurgery, Department of Surgery, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Todd C Hankinson
- 15Division of Pediatric Neurosurgery, Department of Neurosurgery, University of Colorado School of Medicine, Aurora, Colorado
| | - Eric M Jackson
- 16Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland; and
| | - Brandon G Rocque
- 5Section of Pediatric Neurosurgery, Division of Neurosurgery, Children's Hospital of Alabama, University of Alabama-Birmingham, Alabama
| | - Ron Reeder
- 2Department of Pediatrics, University of Utah, Salt Lake City, Utah
| | - James M Drake
- 3Division of Neurosurgery, Hospital for Sick Children, University of Toronto, Ontario, Canada
| | - John R W Kestle
- 17Department of Neurosurgery, University of Utah, Salt Lake City, Utah
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27
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Williams MA, Nagel SJ, Golomb J, Jensen H, Dasher NA, Holubkov R, Edwards RJ, Luciano MG, Zwimpfer TJ, Katzen H, Moghekar A, Wisoff JH, McKhann GM, Hamilton MG. Safety and effectiveness of the assessment and treatment of idiopathic normal pressure hydrocephalus in the Adult Hydrocephalus Clinical Research Network. J Neurosurg 2022; 137:1-13. [PMID: 35276651 DOI: 10.3171/2022.1.jns212782] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2021] [Accepted: 01/24/2022] [Indexed: 11/06/2022]
Abstract
OBJECTIVE The aim of this study was to describe the processes and outcomes associated with patients at five sites in the Adult Hydrocephalus Clinical Research Network (AHCRN) who had undergone evaluation and treatment for suspected idiopathic normal pressure hydrocephalus (iNPH) and had 1-year postoperative follow-up. METHODS Subjects with possible iNPH who had been prospectively enrolled in the AHCRN registry between November 19, 2014, and December 31, 2018, were evaluated by CSF drainage via either lumbar puncture or external lumbar drainage, consistent with recommendations of the international iNPH guidelines. Standardized clinical evaluations of gait, cognition, urinary symptoms, depression, and functional outcomes were conducted at baseline, before and after CSF drainage, and at 4-month intervals after shunt surgery. Complications of CSF drainage and shunt surgery were recorded. RESULTS Seventy-four percent (424/570) of patients with possible iNPH had CSF drainage, and 46% of them (193/424) underwent shunt surgery. The mean change in gait velocity with CSF drainage was 0.18 m/sec in patients who underwent shunt surgery versus 0.08 m/sec in patients who did not. For shunt surgery patients, gait velocity increased by 54% from 0.67 m/sec before CSF drainage to 0.96 m/sec 8-12 months after surgery, and 80% of patients had an increase of at least 0.1 m/sec by the first postoperative visit. Evaluation of cognition, urinary symptoms, depression, and functional outcomes also revealed improvement after shunt surgery. Of 193 patients who had undergone shunt surgery, 176 (91%) had no complications and 17 (9%) had 28 complications. Eleven patients (6%) had 14 serious complications that resulted in the need for surgery or an extended hospital stay. The 30-day reoperation rate was 3%. CONCLUSIONS Using criteria recommended by the international iNPH guidelines, the authors found that evaluation and treatment of iNPH are safe and effective. Testing with CSF drainage and treatment with shunt surgery are associated with a high rate of sustained improvement and a low rate of complications for iNPH in the 1st year after shunt surgery. Patients who had undergone shunt surgery for iNPH experienced improvement in gait, cognitive function, bladder symptoms, depression, and functional outcome measures. Gait velocity, which is an easily measured, objective, continuous variable, should be used as a standard outcome measure to test a patient's response to CSF drainage and shunt surgery in iNPH.
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Affiliation(s)
- Michael A Williams
- 1Departments of Neurology and Neurological Surgery, University of Washington School of Medicine, Seattle, Washington
| | - Sean J Nagel
- 2Department of Neurosurgery, Center for Neurological Restoration, Cleveland Clinic, Cleveland, Ohio
| | - James Golomb
- 3Department of Neurology, New York University School of Medicine, New York, New York
| | - Hailey Jensen
- 4Department of Pediatrics, University of Utah, Salt Lake City, Utah
| | - Nickolas A Dasher
- 5Department of Rehabilitation Medicine, University of Washington School of Medicine, Seattle, Washington
| | - Richard Holubkov
- 4Department of Pediatrics, University of Utah, Salt Lake City, Utah
| | - Richard J Edwards
- 6Department of Neurosurgery, Southmead Hospital, Bristol, United Kingdom
| | - Mark G Luciano
- 7Department of Neurosurgery, Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Thomas J Zwimpfer
- 8Division of Neurosurgery, Department of Surgery, University of British Columbia, Vancouver, British Columbia, Canada
| | - Heather Katzen
- 9Department of Neurology, University of Miami Miller School of Medicine, Miami, Florida
| | - Abhay Moghekar
- 10Department of Neurology, Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Jeffrey H Wisoff
- 11Division of Pediatric Neurosurgery, Hassenfeld Children's Hospital at NYU Langone Health, New York, New York
| | - Guy M McKhann
- 12Department of Neurological Surgery, Columbia University School of Medicine, New York, New York; and
| | - Mark G Hamilton
- 13Department of Clinical Neurosciences, Division of Neurosurgery, University of Calgary School of Medicine, Calgary, Alberta, Canada
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28
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Isaacs AM, Ball CG, Sader N, Muram S, Ben-Israel D, Urbaneja G, Dronyk J, Holubkov R, Hamilton MG. Reducing the risks of proximal and distal shunt failure in adult hydrocephalus: a shunt outcomes quality improvement study. J Neurosurg 2022; 136:877-886. [PMID: 34450584 DOI: 10.3171/2021.2.jns202970] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2020] [Accepted: 02/11/2021] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Patient outcomes of ventriculoperitoneal (VP) shunt surgery, the mainstay treatment for hydrocephalus in adults, are poor because of high shunt failure rates. The use of neuronavigation or laparoscopy can reduce the risks of proximal or distal shunt catheter failure, respectively, but has less independent effect on overall shunt failures. No adult studies to date have combined both approaches in the setting of a shunt infection prevention protocol to reduce shunt failure. The goal of this study was to determine whether combining neuronavigation and laparoscopy with a shunt infection prevention strategy would reduce the incidence of shunt failures in adult hydrocephalic patients. METHODS Adult patients (age ≥ 18 years) undergoing VP shunt surgery at a tertiary care institution prior to (pre-Shunt Outcomes [ShOut]) and after (post-ShOut) the start of a prospective continuous quality improvement (QI) study were compared. Pre-ShOut patients had their proximal and distal catheters placed under conventional freehand approaches. Post-ShOut patients had their shunts inserted with neuronavigational and laparoscopy assistance in placing the distal catheter in the perihepatic space (falciform technique). A shunt infection reduction protocol had been instituted 1.5 years prior to the start of the QI initiative. The primary outcome of interest was the incidence of shunt failure (including infection) confirmed by standardized criteria indicating shunt revision surgery. RESULTS There were 244 (115 pre-ShOut and 129 post-ShOut) patients observed over 7 years. With a background of shunt infection prophylaxis, combined neuronavigation and laparoscopy was associated with a reduction in overall shunt failure rates from 37% to 14%, 45% to 22%, and 51% to 29% at 1, 2, and 3 years, respectively (HR 0.44, p < 0.001). Shunt infection rates decreased from 8% in the pre-ShOut group to 0% in the post-ShOut group. There were no proximal catheter failures in the post-ShOut group. The 2-year rates of distal catheter failure were 42% versus 20% in the pre- and post-ShOut groups, respectively (p < 0.001). CONCLUSIONS Introducing a shunt infection prevention protocol, placing the proximal catheter under neuronavigation, and placing the peritoneal catheter in the perihepatic space by using the falciform technique led to decreased rates of infection, distal shunt failure, and overall shunt failure.
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Affiliation(s)
| | - Chad G Ball
- 2Department of Surgery, University of Calgary
| | | | | | | | - Geberth Urbaneja
- 3Adult Hydrocephalus Program, Department of Clinical Neuroscience, University of Calgary, Alberta, Canada; and
| | - Jarred Dronyk
- 3Adult Hydrocephalus Program, Department of Clinical Neuroscience, University of Calgary, Alberta, Canada; and
| | - Richard Holubkov
- 4Department of Pediatrics, University of Utah School of Medicine, Salt Lake City, Utah
| | - Mark G Hamilton
- 1Division of Neurosurgery, University of Calgary.,3Adult Hydrocephalus Program, Department of Clinical Neuroscience, University of Calgary, Alberta, Canada; and
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Suttle M, Hall MW, Pollack MM, Berg RA, McQuillen PS, Mourani PM, Sapru A, Carcillo JA, Startup E, Holubkov R, Notterman DA, Colville G, Meert KL. Post-Traumatic Growth in Parents following Their Child's Death in a Pediatric Intensive Care Unit. J Palliat Med 2022; 25:265-273. [PMID: 34612728 PMCID: PMC8861930 DOI: 10.1089/jpm.2021.0290] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023] Open
Abstract
Background: Although bereaved parents suffer greatly, some may experience positive change referred to as post-traumatic growth. Objective: Explore the extent to which parents perceive post-traumatic growth after their child's death in a pediatric intensive care unit (PICU), and associated factors. Design: Longitudinal parent survey conducted 6 and 13 months after a child's death. Surveys included the Post-traumatic Growth Inventory-Short Form (PTGI-SF), a 10-item measure with range of 0-50 where higher scores indicate more post-traumatic growth. Surveys also included the Inventory of Complicated Grief (ICG), the Patient Health Questionnaire-8 (PHQ-8) for depression, the Short Post-Traumatic Stress Disorder Rating Interview (SPRINT), a single item on perceived overall health, and sociodemographics. Setting/Subjects: One hundred fifty-seven parents of 104 children who died in 1 of 8 PICUs affiliated with the U.S. Collaborative Pediatric Critical Care Research Network. Results: Of participating parents, 62.4% were female, 71.6% White, 82.7% married, and 89.2% had at least a high school education. Mean PTGI-SF scores were 27.5 ± 12.52 (range 5-50) at 6 months and 28.6 ± 11.52 (range 2-49) at 13 months (p = 0.181). On multivariate modeling, higher education (compared with those not completing high school) and higher 6-month ICG scores (reflecting more complicated grief symptoms) were associated with lower 13-month PTGI-SF scores (p = 0.005 and 0.033, respectively). Conclusion: Parents bereaved by their child's PICU death perceive a moderate degree of post-traumatic growth in the first 13 months after the death however variability is wide. Education level and complicated grief symptoms may influence parents' perception of post-traumatic growth.
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Affiliation(s)
- Markita Suttle
- Department of Pediatrics, Nationwide Children's Hospital, Columbus, Ohio, USA
| | - Mark W. Hall
- Department of Pediatrics, Nationwide Children's Hospital, Columbus, Ohio, USA
| | - Murray M. Pollack
- Department of Pediatrics, Children's National Hospital, Washington, DC, USA
| | - Robert A. Berg
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Patrick S. McQuillen
- Department of Pediatrics, Benioff Children's Hospital, University of California, San Francisco, San Francisco, California, USA
| | - Peter M. Mourani
- Department of Pediatrics, University of Arkansas for Medical Sciences, Arkansas Children's Research Institute, Little Rock, Arkansas, USA
| | - Anil Sapru
- Department of Pediatrics, Mattel Children's Hospital, University of California Los Angeles, Los Angeles, California, USA
| | - Joseph A. Carcillo
- Department of Critical Care Medicine, Children's Hospital of Pittsburgh, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Emily Startup
- Department of Pediatrics, University of Utah, Salt Lake City, Utah, USA
| | - Richard Holubkov
- Department of Pediatrics, University of Utah, Salt Lake City, Utah, USA
| | - Daniel A. Notterman
- Department of Molecular Biology, Princeton University, Princeton, New Jersey, USA
| | - Gillian Colville
- St. George's University Hospitals National Health Service Foundation Trust, London, United Kingdom
| | - Kathleen L. Meert
- Department of Pediatrics, Children's Hospital of Michigan, Detroit, Michigan, USA.,Department of Pediatrics, Central Michigan University, Mt. Pleasant, Michigan, USA.,Address correspondence to: Kathleen L. Meert, MD, Department of Pediatrics, Children's Hospital of Michigan, 3901 Beaubien, Detroit, MI 48201, USA
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Muszynski JA, Banks R, Reeder RW, Hall MW, Berg RA, Zuppa A, Shanley TP, Cornell TT, Newth CJL, Pollack MM, Wessel D, Doctor A, Lin JC, Harrison RE, Meert KL, Dean JM, Holubkov R, Carcillo JA. Outcomes Associated With Early RBC Transfusion in Pediatric Severe Sepsis: A Propensity-Adjusted Multicenter Cohort Study. Shock 2022; 57:88-94. [PMID: 34628452 PMCID: PMC8678199 DOI: 10.1097/shk.0000000000001863] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
BACKGROUND Little is known about the epidemiology of and outcomes related to red blood cell (RBC) transfusion in septic children across multiple centers. We performed propensity-adjusted secondary analyses of the Biomarker Phenotyping of Pediatric Sepsis and Multiple Organ Failure (PHENOMS) study to test the hypothesis that early RBC transfusion is associated with fewer organ failure-free days in pediatric severe sepsis. METHODS Four hundred one children were enrolled in the parent study. Children were excluded from these analyses if they received extracorporeal membrane oxygenation (n = 22) or died (n = 1) before sepsis day 2. Propensity-adjusted analyses compared children who received RBC transfusion on or before sepsis day 2 (early RBC transfusion) with those who did not. Logistic regression was used to model the propensity to receive early RBC transfusion. A weighted cohort was constructed using stabilized inverse probability of treatment weights. Variables in the weighted cohort with absolute standardized differences >0.15 were added to final multivariable models. RESULTS Fifty percent of children received at least one RBC transfusion. The majority (68%) of first transfusions were on or before sepsis day 2. Early RBC transfusion was not independently associated with organ failure-free (-0.34 [95%CI: -2, 1.3] days) or PICU-free days (-0.63 [-2.3, 1.1]), but was associated with the secondary outcome of higher mortality (aOR 2.9 [1.1, 7.9]). CONCLUSIONS RBC transfusion is common in pediatric severe sepsis and may be associated with adverse outcomes. Future studies are needed to clarify these associations, to understand patient-specific transfusion risks, and to develop more precise transfusion strategies.
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Affiliation(s)
- Jennifer A Muszynski
- Division of Critical Care, Department of Pediatrics, Nationwide Children's Hospital, Columbus, Ohio
- Center for Clinical and Translational Research, Abigail Wexner Research Institute at Nationwide Children's Hospital, Columbus, Ohio
| | - Russell Banks
- Department of Pediatrics, University of Utah, Salt Lake City, Utah
| | - Ron W Reeder
- Department of Pediatrics, University of Utah, Salt Lake City, Utah
| | - Mark W Hall
- Division of Critical Care, Department of Pediatrics, Nationwide Children's Hospital, Columbus, Ohio
- Center for Clinical and Translational Research, Abigail Wexner Research Institute at Nationwide Children's Hospital, Columbus, Ohio
| | - Robert A Berg
- Department of Anesthesiology and Critical Care, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Athena Zuppa
- Department of Anesthesiology and Critical Care, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Thomas P Shanley
- Department of Pediatrics, Mott Children's Hospital, Ann Arbor, Michigan
| | - Timothy T Cornell
- Department of Pediatrics, Mott Children's Hospital, Ann Arbor, Michigan
| | - Christopher J L Newth
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital Los Angeles, Los Angeles, California
| | - Murray M Pollack
- Department of Pediatrics, Children's National Medical Center, Washington, District of Columbia
| | - David Wessel
- Department of Pediatrics, Children's National Medical Center, Washington, District of Columbia
| | - Allan Doctor
- Department of Pediatrics, Washington University at Saint Louis, Saint Louis, Missouri
| | - John C Lin
- Department of Pediatrics, Washington University at Saint Louis, Saint Louis, Missouri
| | - Rick E Harrison
- Department of Pediatrics, UCLA Mattel Children's Hospital, Los Angeles, California
| | - Kathleen L Meert
- Division of Critical Care, Department of Pediatrics, Children's Hospital of Michigan, Central Michigan University, Detroit, Michigan
| | - J Michael Dean
- Department of Pediatrics, University of Utah, Salt Lake City, Utah
| | - Richard Holubkov
- Department of Pediatrics, University of Utah, Salt Lake City, Utah
| | - Joseph A Carcillo
- Department of Critical Care Medicine, Children's Hospital of Pittsburgh, Pittsburgh, Pennsylvania
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Kernan KF, Ghaloul-Gonzalez L, Vockley J, Lamb J, Hollingshead D, Chandran U, Sethi R, Park HJ, Berg RA, Wessel D, Pollack MM, Meert KL, Hall MW, Newth CJL, Lin JC, Doctor A, Shanley T, Cornell T, Harrison RE, Zuppa AF, Banks R, Reeder RW, Holubkov R, Notterman DA, Dean JM, Carcillo JA. Prevalence of Pathogenic and Potentially Pathogenic Inborn Error of Immunity Associated Variants in Children with Severe Sepsis. J Clin Immunol 2022; 42:350-364. [PMID: 34973142 PMCID: PMC8720168 DOI: 10.1007/s10875-021-01183-4] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2021] [Accepted: 11/15/2021] [Indexed: 12/29/2022]
Abstract
Purpose Our understanding of inborn errors of immunity is increasing; however, their contribution to pediatric sepsis is unknown. Methods We used whole-exome sequencing (WES) to characterize variants in genes related to monogenic immunologic disorders in 330 children admitted to intensive care for severe sepsis. We defined candidate variants as rare variants classified as pathogenic or potentially pathogenic in QIAGEN’s Human Gene Mutation Database or novel null variants in a disease-consistent inheritance pattern. We investigated variant correlation with infection and inflammatory phenotype. Results More than one in two children overall and three of four African American children had immunodeficiency-associated variants. Children with variants had increased odds of isolating a blood or urinary pathogen (blood: OR 2.82, 95% CI: 1.12–7.10, p = 0.023, urine: OR: 8.23, 95% CI: 1.06–64.11, p = 0.016) and demonstrating increased inflammation with hyperferritinemia (ferritin \documentclass[12pt]{minimal}
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\begin{document}$$\ge 500$$\end{document}≥500 ng/mL, OR: 2.16, 95% CI: 1.28–3.66, p = 0.004), lymphopenia (lymphocyte count < 1000/µL, OR: 1.66, 95% CI: 1.06 – 2.60, p = 0.027), thrombocytopenia (platelet count < 150,000/µL, OR: 1.76, 95% CI: 1.12–2.76, p = 0.013), and CRP greater than 10 mg/dl (OR: 1.71, 95% CI: 1.10–2.68, p = 0.017). They also had increased odds of requiring extracorporeal membrane oxygenation (ECMO, OR: 4.19, 95% CI: 1.21–14.5, p = 0.019). Conclusion Herein, we describe the genetic findings in this severe pediatric sepsis cohort and their microbiologic and immunologic significance, providing evidence for the phenotypic effect of these variants and rationale for screening children with life-threatening infections for potential inborn errors of immunity. Supplementary Information The online version contains supplementary material available at 10.1007/s10875-021-01183-4.
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Affiliation(s)
- Kate F Kernan
- Division of Pediatric Critical Care Medicine, Department of Critical Care Medicine, Center for Critical Care Nephrology and Clinical Research Investigation and Systems Modeling of Acute Illness Center, Children's Hospital of Pittsburgh, University of Pittsburgh, Pittsburgh, PA, USA.
| | - Lina Ghaloul-Gonzalez
- Division of Genetic and Genomic Medicine, Department of Pediatrics, Children's Hospital of Pittsburgh, University of Pittsburgh, Pittsburgh, PA, USA
| | - Jerry Vockley
- Division of Genetic and Genomic Medicine, Department of Pediatrics, Children's Hospital of Pittsburgh, University of Pittsburgh, Pittsburgh, PA, USA
| | - Janette Lamb
- Genomics Core Laboratory, University of Pittsburgh, Pittsburgh, PA, USA
| | | | - Uma Chandran
- Department of Biomedical Informatics, University of Pittsburgh, Pittsburgh, PA, USA
| | - Rahil Sethi
- Department of Biomedical Informatics, University of Pittsburgh, Pittsburgh, PA, USA
| | - Hyun-Jung Park
- Department of Genetics, Graduate School of Public Health, University of Pittsburgh, Pittsburgh, PA, USA
| | - Robert A Berg
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - David Wessel
- Division of Critical Care Medicine, Department of Pediatrics, Children's National Hospital, Washington, DC, USA
| | - Murray M Pollack
- Division of Critical Care Medicine, Department of Pediatrics, Children's National Hospital, Washington, DC, USA
| | - Kathleen L Meert
- Division of Critical Care Medicine, Department of Pediatrics, Children's Hospital of Michigan, Detroit, MI, USA
- Central Michigan University, Mt. Pleasant, MI, USA
| | - Mark W Hall
- Division of Critical Care Medicine, Department of Pediatrics, The Research Institute at Nationwide Children's Hospital Immune Surveillance Laboratory, and Nationwide Children's Hospital, Columbus, OH, USA
| | - Christopher J L Newth
- Division of Pediatric Critical Care Medicine, Department of Anesthesiology and Pediatrics, Children's Hospital Los Angeles, Los Angeles, CA, USA
| | - John C Lin
- Division of Critical Care Medicine, Department of Pediatrics, St. Louis Children's Hospital, St. Louis, MO, USA
| | - Allan Doctor
- Division of Critical Care Medicine, Department of Pediatrics, St. Louis Children's Hospital, St. Louis, MO, USA
- Division of Pediatric Critical Care Medicine, The Center for Blood Oxygen Transport and Hemostasis, University of Maryland School of Medicine, MD, Baltimore, USA
| | - Tom Shanley
- Division of Critical Care Medicine, Department of Pediatrics, C. S. Mott Children's Hospital, Ann Arbor, MI, USA
| | - Tim Cornell
- Division of Critical Care Medicine, Department of Pediatrics, C. S. Mott Children's Hospital, Ann Arbor, MI, USA
- Department of Pediatrics, Lucile Packard Children's Hospital Stanford, Stanford University, CA, Palo Alto, USA
| | - Rick E Harrison
- Division of Critical Care Medicine, Department of Pediatrics, Mattel Children's Hospital at University of California Los Angeles, Los Angeles, CA, USA
| | - Athena F Zuppa
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Russel Banks
- Department of Pediatrics, University of Utah, Salt Lake City, UT, USA
| | - Ron W Reeder
- Department of Pediatrics, University of Utah, Salt Lake City, UT, USA
| | - Richard Holubkov
- Department of Pediatrics, University of Utah, Salt Lake City, UT, USA
| | - Daniel A Notterman
- Department of Molecular Biology, Princeton University, Princeton, NJ, USA
| | - J Michael Dean
- Department of Pediatrics, University of Utah, Salt Lake City, UT, USA
| | - Joseph A Carcillo
- Division of Pediatric Critical Care Medicine, Department of Critical Care Medicine, Center for Critical Care Nephrology and Clinical Research Investigation and Systems Modeling of Acute Illness Center, Children's Hospital of Pittsburgh, University of Pittsburgh, Pittsburgh, PA, USA
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Jensen AR, Evans LL, Meert KL, VanBuren JM, Richards R, Alvey JS, Holubkov R, Pollack MM, Burd RS. Functional status impairment at six-month follow-up is independently associated with child physical abuse mechanism. Child Abuse Negl 2021; 122:105333. [PMID: 34583299 DOI: 10.1016/j.chiabu.2021.105333] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/09/2021] [Revised: 09/11/2021] [Accepted: 09/14/2021] [Indexed: 06/13/2023]
Abstract
BACKGROUND Children with abusive injuries have worse mortality, length-of-stay, complications, and healthcare costs compared to those sustaining an accidental injury. Long-term functional impairment is common in children with abusive head trauma but has not been examined in a cohort with heterogeneous body region injuries. OBJECTIVE To assess for an independent association between child physical abuse and functional impairment at discharge and six-month follow-up. PARTICIPANTS AND SETTING Seriously injured children (<15 years) treated at seven pediatric trauma centers. METHODS Functional status was compared between child physical abuse and accidental injury groups at discharge and six-month follow-up. Functional impairment was defined at discharge ("new domain morbidity") as a change from pre-injury ≥2 points in any of the six domains of the Functional Status Scale (FSS), and impairment at six-month follow-up as an abnormal total FSS score. RESULTS Children with abusive injuries accounted for 10.5% (n = 45) of the cohort. New domain morbidity was present in 17.8% (n = 8) of child physical abuse patients at discharge, with 10% (n = 3) of children having an abnormal FSS at six-months. There were no differences in new domain morbidity at hospital discharge between children injured by abuse and or accidental injury. However, children injured by physical abuse were 4.09 (2.15, 7.78) times more likely to have functional impairment at six months. CONCLUSIONS Child physical abuse is an independent risk factor for functional impairment at six-month follow-up. Functional status measurement for this high-risk group of children should be routinely measured and incorporated into trauma center quality assessments.
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Affiliation(s)
- Aaron R Jensen
- Division of Pediatric Surgery, UCSF Benioff Children's Hospitals, and Department of Surgery, University of California San Francisco, San Francisco, CA 94611, USA.
| | - Lauren L Evans
- Division of Pediatric Surgery, UCSF Benioff Children's Hospitals, and Department of Surgery, University of California San Francisco, San Francisco, CA 94611, USA.
| | - Kathleen L Meert
- Department of Pediatrics, Children's Hospital of Michigan, Central Michigan University, Detroit, MI, 48201, USA.
| | - John M VanBuren
- Department of Pediatrics, University of Utah School of Medicine, Salt Lake City, UT 84108, USA.
| | - Rachel Richards
- Department of Pediatrics, University of Utah School of Medicine, Salt Lake City, UT 84108, USA.
| | - Jessica S Alvey
- Department of Pediatrics, University of Utah School of Medicine, Salt Lake City, UT 84108, USA.
| | - Richard Holubkov
- Department of Pediatrics, University of Utah School of Medicine, Salt Lake City, UT 84108, USA.
| | - Murray M Pollack
- Department of Pediatrics, Children's National Health System, George Washington University School of Medicine and Health Sciences, Washington, DC 20010, USA.
| | - Randall S Burd
- Division of Trauma and Burn Surgery, Children's National Medical Center, Washington, DC 20010, USA.
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Whitehead WE, Riva-Cambrin J, Wellons JC, Kulkarni AV, Limbrick DD, Wall VL, Rozzelle CJ, Hankinson TC, McDonald PJ, Krieger MD, Pollack IF, Tamber MS, Pindrik J, Hauptman JS, Naftel RP, Shannon CN, Chu J, Jackson EM, Browd SR, Simon TD, Holubkov R, Reeder RW, Jensen H, Koschnitzky JE, Gross P, Drake JM, Kestle JRW. Anterior versus posterior entry site for ventriculoperitoneal shunt insertion: a randomized controlled trial by the Hydrocephalus Clinical Research Network. J Neurosurg Pediatr 2021:1-11. [PMID: 34798600 DOI: 10.3171/2021.9.peds21391] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/27/2021] [Accepted: 09/02/2021] [Indexed: 11/06/2022]
Abstract
OBJECTIVE The primary objective of this trial was to determine if shunt entry site affects the risk of shunt failure. METHODS The authors performed a parallel-design randomized controlled trial with an equal allocation of patients who received shunt placement via the anterior entry site and patients who received shunt placement via the posterior entry site. All patients were children with symptoms or signs of hydrocephalus and ventriculomegaly. Patients were ineligible if they had a prior history of shunt insertion. Patients received a ventriculoperitoneal shunt after randomization; randomization was stratified by surgeon. The primary outcome was shunt failure. The planned minimum follow-up was 18 months. The trial was designed to achieve high power to detect a 10% or greater absolute difference in the shunt failure rate at 1 year. An independent, blinded adjudication committee determined eligibility and the primary outcome. The study was conducted by the Hydrocephalus Clinical Research Network. RESULTS The study randomized 467 pediatric patients at 14 tertiary care pediatric hospitals in North America from April 2015 to January 2019. The adjudication committee, blinded to intervention, excluded 7 patients in each group for not meeting the study inclusion criteria. For the primary analysis, there were 229 patients in the posterior group and 224 patients in the anterior group. The median patient age was 1.3 months, and the most common etiologies of hydrocephalus were postintraventricular hemorrhage secondary to prematurity (32.7%), myelomeningocele (16.8%), and aqueductal stenosis (10.8%). There was no significant difference in the time to shunt failure between the entry sites (log-rank test, stratified by age < 6 months and ≥ 6 months; p = 0.061). The hazard ratio (HR) of a posterior shunt relative to an anterior shunt was calculated using a univariable Cox regression model and was nonsignificant (HR 1.35, 95% CI, 0.98-1.85; p = 0.062). No significant difference was found between entry sites for the surgery duration, number of ventricular catheter passes, ventricular catheter location, and hospital length of stay. There were no significant differences between entry sites for intraoperative complications, postoperative CSF leaks, pseudomeningoceles, shunt infections, skull fractures, postoperative seizures, new-onset epilepsy, or intracranial hemorrhages. CONCLUSIONS This randomized controlled trial comparing the anterior and posterior shunt entry sites has demonstrated no significant difference in the time to shunt failure. Anterior and posterior entry site surgeries were found to have similar outcomes and similar complication rates.
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Affiliation(s)
| | - Jay Riva-Cambrin
- 2Department of Neurosurgery, University of Calgary, Calgary, Alberta, Canada
| | - John C Wellons
- 3Department of Neurosurgery, Vanderbilt University, Nashville, Tennessee
| | - Abhaya V Kulkarni
- 4Department of Neurosurgery, University of Toronto, Toronto, Ontario, Canada
| | - David D Limbrick
- 5Department of Neurosurgery, Washington University, St. Louis, Missouri
| | - Vanessa L Wall
- 6Department of Pediatrics, University of Utah, Salt Lake City, Utah
| | - Curtis J Rozzelle
- 7Department of Neurosurgery, University of Alabama, Birmingham, Alabama
| | - Todd C Hankinson
- 8Department of Neurosurgery, University of Colorado, Aurora, Colorado
| | - Patrick J McDonald
- 9Department of Neurosurgery, University of British Columbia, Vancouver, British Columbia, Canada
| | - Mark D Krieger
- 10Department of Neurosurgery, University of Southern California, Los Angeles, California
| | - Ian F Pollack
- 11Department of Neurosurgery, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Mandeep S Tamber
- 9Department of Neurosurgery, University of British Columbia, Vancouver, British Columbia, Canada
| | - Jonathan Pindrik
- 12Department of Neurosurgery, Ohio State University, Columbus, Ohio
| | - Jason S Hauptman
- 13Department of Neurosurgery, University of Washington, Seattle, Washington
| | - Robert P Naftel
- 3Department of Neurosurgery, Vanderbilt University, Nashville, Tennessee
| | - Chevis N Shannon
- 3Department of Neurosurgery, Vanderbilt University, Nashville, Tennessee
| | - Jason Chu
- 10Department of Neurosurgery, University of Southern California, Los Angeles, California
| | - Eric M Jackson
- 14Department of Neurosurgery, Johns Hopkins University, Baltimore, Maryland
| | - Samuel R Browd
- 13Department of Neurosurgery, University of Washington, Seattle, Washington
| | - Tamara D Simon
- 15Department of Pediatrics, Keck School of Medicine at the University of Southern California, Los Angeles, California
| | - Richard Holubkov
- 6Department of Pediatrics, University of Utah, Salt Lake City, Utah
| | - Ron W Reeder
- 6Department of Pediatrics, University of Utah, Salt Lake City, Utah
| | - Hailey Jensen
- 6Department of Pediatrics, University of Utah, Salt Lake City, Utah
| | | | - Paul Gross
- 16Hydrocephalus Association, Washington, DC; and
| | - James M Drake
- 4Department of Neurosurgery, University of Toronto, Toronto, Ontario, Canada
| | - John R W Kestle
- 17Department of Neurosurgery, University of Utah, Salt Lake City, Utah
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Riva-Cambrin J, Kulkarni AV, Burr R, Rozzelle CJ, Oakes WJ, Drake JM, Alvey JS, Reeder RW, Holubkov R, Browd SR, Cochrane DD, Limbrick DD, Naftel R, Shannon CN, Simon TD, Tamber MS, McDonald PJ, Wellons JC, Luerssen TG, Whitehead WE, Kestle JRW. Impact of ventricle size on neuropsychological outcomes in treated pediatric hydrocephalus: an HCRN prospective cohort study. J Neurosurg Pediatr 2021:1-12. [PMID: 34767531 DOI: 10.3171/2021.8.peds21146] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/17/2021] [Accepted: 08/19/2021] [Indexed: 11/06/2022]
Abstract
OBJECTIVE In pediatric hydrocephalus, shunts tend to result in smaller postoperative ventricles compared with those following an endoscopic third ventriculostomy (ETV). The impact of the final treated ventricle size on neuropsychological and quality-of-life outcomes is currently undetermined. Therefore, the authors sought to ascertain whether treated ventricle size is associated with neurocognitive and academic outcomes postoperatively. METHODS This prospective cohort study included children aged 5 years and older at the first diagnosis of hydrocephalus at 8 Hydrocephalus Clinical Research Network sites from 2011 to 2015. The treated ventricle size, as measured by the frontal and occipital horn ratio (FOR), was compared with 25 neuropsychological tests 6 months postoperatively after adjusting for age, hydrocephalus etiology, and treatment type (ETV vs shunt). Pre- and posttreatment grade point average (GPA), quality-of-life measures (Hydrocephalus Outcome Questionnaire [HOQ]), and a truncated preoperative neuropsychological battery were also compared with the FOR. RESULTS Overall, 60 children were included with a mean age of 10.8 years; 17% had ≥ 1 comorbidity. Etiologies for hydrocephalus were midbrain lesions (37%), aqueductal stenosis (22%), posterior fossa tumors (13%), and supratentorial tumors (12%). ETV (78%) was more commonly used than shunting (22%). Of the 25 neuropsychological tests, including full-scale IQ (q = 0.77), 23 tests showed no univariable association with postoperative ventricle size. Verbal learning delayed recall (p = 0.006, q = 0.118) and visual spatial judgment (p = 0.006, q = 0.118) were negatively associated with larger ventricles and remained significant after multivariate adjustment for age, etiology, and procedure type. However, neither delayed verbal learning (p = 0.40) nor visual spatial judgment (p = 0.22) was associated with ventricle size change with surgery. No associations were found between postoperative ventricle size and either GPA or the HOQ. CONCLUSIONS Minimal associations were found between the treated ventricle size and neuropsychological, academic, or quality-of-life outcomes for pediatric patients in this comprehensive, multicenter study that encompassed heterogeneous hydrocephalus etiologies.
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Affiliation(s)
- Jay Riva-Cambrin
- 1Department of Clinical Neurosciences, Alberta Children's Hospital, University of Calgary, Alberta, Canada
| | - Abhaya V Kulkarni
- 2Department of Neurosurgery, Hospital for Sick Children, University of Toronto, Ontario, Canada
| | - Robert Burr
- 4Department of Neurosurgery, University of Utah, Salt Lake City, Utah
| | - Curtis J Rozzelle
- 3Division of Pediatric Neurosurgery, Children's of Alabama, Birmingham, Alabama
| | - W Jerry Oakes
- 3Division of Pediatric Neurosurgery, Children's of Alabama, Birmingham, Alabama
| | - James M Drake
- 2Department of Neurosurgery, Hospital for Sick Children, University of Toronto, Ontario, Canada
| | - Jessica S Alvey
- 4Department of Neurosurgery, University of Utah, Salt Lake City, Utah
| | - Ron W Reeder
- 4Department of Neurosurgery, University of Utah, Salt Lake City, Utah
| | - Richard Holubkov
- 4Department of Neurosurgery, University of Utah, Salt Lake City, Utah
| | - Samuel R Browd
- 5Department of Neurological Surgery, Seattle Children's Hospital, Seattle, Washington
| | - D Douglas Cochrane
- 6Division of Pediatric Neurosurgery, BC Children's Hospital, University of British Columbia, Vancouver, Canada
| | - David D Limbrick
- 7Department of Neurosurgery, St. Louis Children's Hospital, St. Louis, Missouri
| | - Robert Naftel
- 8Department of Neurological Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Chevis N Shannon
- 8Department of Neurological Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Tamara D Simon
- 9Department of Pediatrics, University of Southern California, Los Angeles, California; and
| | - Mandeep S Tamber
- 6Division of Pediatric Neurosurgery, BC Children's Hospital, University of British Columbia, Vancouver, Canada
| | - Patrick J McDonald
- 6Division of Pediatric Neurosurgery, BC Children's Hospital, University of British Columbia, Vancouver, Canada
| | - John C Wellons
- 8Department of Neurological Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Thomas G Luerssen
- 10Department of Pediatric Neurosurgery, Texas Children's Hospital, Houston, Texas
| | - William E Whitehead
- 10Department of Pediatric Neurosurgery, Texas Children's Hospital, Houston, Texas
| | - John R W Kestle
- 4Department of Neurosurgery, University of Utah, Salt Lake City, Utah
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Kahleova H, Berrien-Lopez R, Holtz D, Green A, Sheinberg R, Gujral H, Holubkov R, Barnard ND. Nutrition for Hospital Workers During a Crisis: Effect of a Plant-Based Dietary Intervention on Cardiometabolic Outcomes and Quality of Life in Healthcare Employees During the COVID-19 Pandemic. Am J Lifestyle Med 2021; 16:399-407. [PMID: 35698577 PMCID: PMC9184832 DOI: 10.1177/15598276211050339] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023] Open
Abstract
The study tested the effects of a vegan diet on cardiometabolic outcomes and quality of
life among healthcare employees during the COVID-19 pandemic. Overweight hospital
employees were enrolled and randomly assigned (in a 1:1 ratio) to an intervention group,
which was asked to follow a low-fat vegan diet, or a control group, asked to make no diet
changes. However, due to COVID-19 disruptions, all participants remained on their usual
diets from March to June (12 weeks), creating a de facto control period, and all (n = 12)
started the vegan diet with online classes in June, which continued for 12 weeks. Nine
participants completed all final assessments. A crossover ANOVA was used for statistical
analysis of differences in cardiovascular health during the control period and during the
intervention. Despite the ongoing crisis, body weight decreased (treatment effect −5.7 kg
[95% CI −9.7 to −1.7]; P = .01); fasting plasma glucose decreased
(−11.4 mg/dL [95% CI −18.8 to −4.1]; P = .007); total and LDL-cholesterol
decreased (−30.7 mg/dL [95% CI −53.8 to −7.5]; P = .02; and −24.6 mg/dL
[−44.8 to −4.3]; P = .02, respectively); diastolic blood pressure
decreased (−8.5 mm Hg [95% CI −16.3 to −.7]; P = .03); and quality of
life increased (P = .005) during the intervention period, compared with
the control period. A vegan diet improved cardiometabolic outcomes and quality of life in
healthcare workers at the height of the COVID-19 pandemic.
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Affiliation(s)
- Hana Kahleova
- Physicians Committee for Responsible Medicine, Washington, DC, USA, (HK, DH, AG, NDB); Adjunct Faculty, George Washington University School of Medicine and Health Sciences, Washington, DC, USA, (NDB); University of Maryland School of Medicine, Baltimore City, MD, USA, (RBL); Sibley Memorial Hospital, Washington, DC, USA, (HG, RS); School of Medicine, University of Utah, Salt Lake City, UT, USA, (RH)
| | - Rickisha Berrien-Lopez
- Physicians Committee for Responsible Medicine, Washington, DC, USA, (HK, DH, AG, NDB); Adjunct Faculty, George Washington University School of Medicine and Health Sciences, Washington, DC, USA, (NDB); University of Maryland School of Medicine, Baltimore City, MD, USA, (RBL); Sibley Memorial Hospital, Washington, DC, USA, (HG, RS); School of Medicine, University of Utah, Salt Lake City, UT, USA, (RH)
| | - Danielle Holtz
- Physicians Committee for Responsible Medicine, Washington, DC, USA, (HK, DH, AG, NDB); Adjunct Faculty, George Washington University School of Medicine and Health Sciences, Washington, DC, USA, (NDB); University of Maryland School of Medicine, Baltimore City, MD, USA, (RBL); Sibley Memorial Hospital, Washington, DC, USA, (HG, RS); School of Medicine, University of Utah, Salt Lake City, UT, USA, (RH)
| | - Amber Green
- Physicians Committee for Responsible Medicine, Washington, DC, USA, (HK, DH, AG, NDB); Adjunct Faculty, George Washington University School of Medicine and Health Sciences, Washington, DC, USA, (NDB); University of Maryland School of Medicine, Baltimore City, MD, USA, (RBL); Sibley Memorial Hospital, Washington, DC, USA, (HG, RS); School of Medicine, University of Utah, Salt Lake City, UT, USA, (RH)
| | - Rosanne Sheinberg
- Physicians Committee for Responsible Medicine, Washington, DC, USA, (HK, DH, AG, NDB); Adjunct Faculty, George Washington University School of Medicine and Health Sciences, Washington, DC, USA, (NDB); University of Maryland School of Medicine, Baltimore City, MD, USA, (RBL); Sibley Memorial Hospital, Washington, DC, USA, (HG, RS); School of Medicine, University of Utah, Salt Lake City, UT, USA, (RH)
| | - Harpreet Gujral
- Physicians Committee for Responsible Medicine, Washington, DC, USA, (HK, DH, AG, NDB); Adjunct Faculty, George Washington University School of Medicine and Health Sciences, Washington, DC, USA, (NDB); University of Maryland School of Medicine, Baltimore City, MD, USA, (RBL); Sibley Memorial Hospital, Washington, DC, USA, (HG, RS); School of Medicine, University of Utah, Salt Lake City, UT, USA, (RH)
| | - Richard Holubkov
- Physicians Committee for Responsible Medicine, Washington, DC, USA, (HK, DH, AG, NDB); Adjunct Faculty, George Washington University School of Medicine and Health Sciences, Washington, DC, USA, (NDB); University of Maryland School of Medicine, Baltimore City, MD, USA, (RBL); Sibley Memorial Hospital, Washington, DC, USA, (HG, RS); School of Medicine, University of Utah, Salt Lake City, UT, USA, (RH)
| | - Neal D. Barnard
- Physicians Committee for Responsible Medicine, Washington, DC, USA, (HK, DH, AG, NDB); Adjunct Faculty, George Washington University School of Medicine and Health Sciences, Washington, DC, USA, (NDB); University of Maryland School of Medicine, Baltimore City, MD, USA, (RBL); Sibley Memorial Hospital, Washington, DC, USA, (HG, RS); School of Medicine, University of Utah, Salt Lake City, UT, USA, (RH)
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Millar MM, Olson LM, VanBuren JM, Richards R, Pollack MM, Holubkov R, Berg RA, Carcillo JA, McQuillen PS, Meert KL, Mourani PM, Burd RS. Incentive delivery timing and follow-up survey completion in a prospective cohort study of injured children: a randomized experiment comparing prepaid and postpaid incentives. BMC Med Res Methodol 2021; 21:233. [PMID: 34706653 PMCID: PMC8549144 DOI: 10.1186/s12874-021-01421-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2021] [Accepted: 09/22/2021] [Indexed: 11/24/2022] Open
Abstract
Background Retaining participants over time is a frequent challenge in research studies evaluating long-term health outcomes. This study’s objective was to compare the impact of prepaid and postpaid incentives on response to a six-month follow-up survey. Methods We conducted an experiment to compare response between participants randomized to receive either prepaid or postpaid cash card incentives within a multisite study of children under 15 years in age who were hospitalized for a serious, severe, or critical injury. Participants were parents or guardians of enrolled children. The primary outcome was survey response. We also examined whether demographic characteristics were associated with response and if incentive timing influenced the relationship between demographic characteristics and response. We evaluated whether incentive timing was associated with the number of calls needed for contact. Results The study enrolled 427 children, and parents of 420 children were included in this analysis. Follow-up survey response did not differ according to the assigned treatment arm, with the percentage of parents responding to the survey being 68.1% for the prepaid incentive and 66.7% with the postpaid incentive. Likelihood of response varied by demographics. Spanish-speaking parents and parents with lower income and lower educational attainment were less likely to respond. Parents of Hispanic/Latino children and children with Medicaid insurance were also less likely to respond. We found no relationship between the assigned incentive treatment and the demographics of respondents compared to non-respondents. Conclusions Prepaid and postpaid incentives can obtain similar participation in longitudinal pediatric critical care outcomes research. Incentives alone do not ensure retention of all demographic subgroups. Strategies for improving representation of hard-to-reach populations are needed to address health disparities and ensure the generalizability of studies using these results. Supplementary Information The online version contains supplementary material available at 10.1186/s12874-021-01421-8.
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Affiliation(s)
- Morgan M Millar
- Department of Internal Medicine, University of Utah School of Medicine, 295 Chipeta Way, Salt Lake City, UT, 84132, USA.
| | - Lenora M Olson
- Department of Pediatrics, University of Utah School of Medicine, 295 Chipeta Way, Salt Lake City, UT, 84108, USA
| | - John M VanBuren
- Department of Pediatrics, University of Utah School of Medicine, 295 Chipeta Way, Salt Lake City, UT, 84108, USA
| | - Rachel Richards
- Department of Pediatrics, University of Utah School of Medicine, 295 Chipeta Way, Salt Lake City, UT, 84108, USA
| | - Murray M Pollack
- Department of Pediatrics, Children's National Health System and the George Washington University School of Medicine and Health Sciences, Washington, DC, USA
| | - Richard Holubkov
- Department of Pediatrics, University of Utah School of Medicine, 295 Chipeta Way, Salt Lake City, UT, 84108, USA
| | - Robert A Berg
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Joseph A Carcillo
- Department of Critical Care Medicine and Pediatrics, Children's Hospital of Pittsburgh, Pittsburgh, PA, USA
| | - Patrick S McQuillen
- Department of Pediatrics, Benioff Children's Hospital, University of California San Francisco, San Francisco, CA, USA
| | - Kathleen L Meert
- Department of Pediatrics, Children's Hospital of Michigan, 3901 Beaubien, Detroit, MI 48201 and, Central Michigan University, Mt. Pleasant, MI, USA.,Central Michigan University, Mt. Pleasant, MI, USA
| | - Peter M Mourani
- Department of Pediatrics, Children's Hospital Colorado and University of Colorado School of Medicine, Aurora, CO, USA
| | - Randall S Burd
- Division of Trauma and Burn Surgery, Children's National Medical Center, 111 Michigan Ave NW, Washington, DC, 20010, USA
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Burd RS, Jensen AR, VanBuren JM, Alvey JS, Richards R, Holubkov R, Pollack MM. Long-Term Outcomes after Pediatric Injury: Results of the Assessment of Functional Outcomes and Health-Related Quality of Life after Pediatric Trauma Study. J Am Coll Surg 2021; 233:666-675.e2. [PMID: 34592405 DOI: 10.1016/j.jamcollsurg.2021.08.693] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2021] [Revised: 07/19/2021] [Accepted: 08/19/2021] [Indexed: 10/20/2022]
Abstract
BACKGROUND Disability and impaired health-related quality of life can persist for months among injured children. Previous studies of long-term outcomes have focused mainly on children with specific injury types rather than those with multiple injured body regions. This study's objective was to determine the long-term functional status and health-related quality of life after serious pediatric injury, and to evaluate the associations of these outcomes with features available at hospital discharge. STUDY DESIGN We conducted a prospective observational study at 7 Level I pediatric trauma centers of children treated for at least 1 serious (Abbreviated Injury Scale severity 3 or higher) injury. Patients were sampled to increase the representation of less frequently injured body regions and multiple injured body regions. Six-month functional status was measured using the Functional Status Scale (FSS) and health-related quality of life using the Pediatric Quality of Life Inventory. RESULTS Among 323 injured children with complete discharge and follow-up assessments, 6-month FSS score was abnormal in 33 patients (10.2%)-16 with persistent impairments and 17 previously normal at discharge. Increasing levels of impaired discharge FSS score were associated with impaired FSS and lower Pediatric Quality of Life Inventory scores at 6-month follow-up. Additional factors on multivariable analysis associated with 6-month FSS impairment included older age, penetrating injury type, severe head injuries, and spine injuries, and included older age for lower 6-month Pediatric Quality of Life Inventory scores. CONCLUSIONS Older age and discharge functional status are associated with long-term impairment of functional status and health-related quality of life. Although most seriously injured children return to normal, ongoing disability and reduced health-related quality of life remained 6 months after injury. Our findings support long-term assessments as standard practice for evaluating the health impacts of serious pediatric injury.
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Affiliation(s)
- Randall S Burd
- Division of Trauma and Burn Surgery, Children's National Medical Center.
| | | | - John M VanBuren
- Department of Pediatrics, University of Utah School of Medicine, Salt Lake City, UT
| | - Jessica S Alvey
- Department of Pediatrics, University of Utah School of Medicine, Salt Lake City, UT
| | - Rachel Richards
- Department of Pediatrics, University of Utah School of Medicine, Salt Lake City, UT
| | - Richard Holubkov
- Department of Pediatrics, University of Utah School of Medicine, Salt Lake City, UT
| | - Murray M Pollack
- Department of Pediatrics, Children's National Health System, George Washington University School of Medicine and Health Sciences, Washington DC
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Zwimpfer TJ, Salterio N, Williams MA, Holubkov R, Katzen H, Luciano MG, Moghekar A, Nagel SJ, Wisoff JH, Golomb J, McKhann GM, Edwards RJ, Hamilton MG. Cognitive and gait outcomes after primary endoscopic third ventriculostomy in adults with chronic obstructive hydrocephalus. J Neurosurg 2021; 136:887-894. [PMID: 34534954 DOI: 10.3171/2021.3.jns203424] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2020] [Accepted: 03/10/2021] [Indexed: 11/06/2022]
Abstract
OBJECTIVE The object of this study was to determine the short- and long-term efficacy of primary endoscopic third ventriculostomy (ETV) on cognition and gait in adults with chronic obstructive hydrocephalus. METHODS Patients were prospectively accrued through the Adult Hydrocephalus Clinical Research Network patient registry. Patients with previously untreated congenital or acquired obstructive hydrocephalus were included in this study. Gait velocity was assessed using a 10-m walk test. Global cognition was assessed with the Montreal Cognitive Assessment (MoCA). Only patients with documented pre- and post-ETV gait analysis and/or pre- and post-ETV MoCA were included. RESULTS A total of 74 patients had undergone primary ETV, 42 of whom were analyzed. The remaining 32 patients were excluded, as they could not complete both pre- and post-ETV assessments. The mean age of the 42 patients, 19 (45.2%) of whom were female, was 51.9 ± 17.1 years (range 19-79 years). Most patients were White (37 [88.1%]), and the remainder were Asian. Surgical complications were minor. Congenital etiologies occurred in 31 patients (73.8%), with aqueductal stenosis in 23 of those patients (54.8%). The remaining 11 patients (26.2%) had acquired cases. The gait short-term follow-up cohort (mean 4.7 ± 4.1 months, 35 patients) had a baseline median gait velocity of 0.9 m/sec (IQR 0.7-1.3 m/sec) and a post-ETV median velocity of 1.3 m/sec (IQR 1.1-1.4 m/sec). Gait velocity significantly improved post-ETV with a median within-patient change of 0.3 m/sec (IQR 0.0-0.6 m/sec, p < 0.001). Gait velocity improvements were sustained in the long term (mean 14 ± 2.8 months, 12 patients) with a baseline median velocity of 0.7 m/sec (IQR 0.6-1.3 m/sec), post-ETV median of 1.3 m/sec (IQR 1.1-1.7 m/sec), and median within-patient change of 0.4 m/sec (IQR 0.2-0.6 m/sec, p < 0.001). The cognitive short-term follow-up cohort (mean 4.6 ± 4.0 months, 38 patients) had a baseline median MoCA total score (MoCA TS) of 24/30 (IQR 23-27) that improved to 26/30 (IQR 24-28) post-ETV. The median within-patient change was +1 point (IQR 0-2 points, p < 0.001). However, this change is not clinically significant. The cognitive long-term follow-up cohort (mean 14 ± 3.1 months, 15 patients) had a baseline median MoCA TS of 23/30 (IQR 22-27), which improved to 26/30 (IQR 25-28) post-ETV. The median within-patient change was +2 points (IQR 1-3 points, p = 0.007), which is both statistically and clinically significant. CONCLUSIONS Primary ETV can safely improve symptoms of gait and cognitive dysfunction in adults with chronic obstructive hydrocephalus. Gait velocity and global cognition were significantly improved, and the worsening of either was rare following ETV.
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Affiliation(s)
- Thomas J Zwimpfer
- 1Department of Surgery, University of British Columbia, Vancouver, British Columbia, Canada
| | - Nicholas Salterio
- 1Department of Surgery, University of British Columbia, Vancouver, British Columbia, Canada
| | - Michael A Williams
- 2Departments of Neurology and Neurological Surgery, University of Washington, Seattle, Washington
| | - Richard Holubkov
- 3Department of Pediatrics, University of Utah, Salt Lake City, Utah
| | - Heather Katzen
- 4Department of Neurology, University of Miami Miller School of Medicine, Miami, Florida
| | | | - Abhay Moghekar
- 6Neurology, Johns Hopkins University, Baltimore, Maryland
| | - Sean J Nagel
- 7Department of Neurosurgery, Center for Neurological Restoration, Cleveland Clinic, Cleveland, Ohio
| | | | - James Golomb
- 9Neurology, New York University School of Medicine, New York, New York
| | - Guy M McKhann
- 10Department of Neurological Surgery, Columbia University Irving Medical Center, New York, New York
| | - Richard J Edwards
- 11Department of Neurosurgery, Southmead Hospital, Bristol, United Kingdom; and
| | - Mark G Hamilton
- 12Department of Clinical Neurosciences, Division of Neurosurgery, University of Calgary Cumming School of Medicine, Calgary, Alberta, Canada
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Branch DW, VanBuren JM, Porter TF, Holmgren C, Holubkov R, Page K, Burchard J, Lam GK, Esplin MS. Prediction and Prevention of Preterm Birth: A Prospective, Randomized Intervention Trial. Am J Perinatol 2021. [PMID: 34399434 DOI: 10.1055/s-0041-1732339] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Abstract
OBJECTIVE The study aimed to determine if a program of mid-trimester serum proteomics screening of women at low risk for spontaneous preterm birth (sPTB) and the use of a PTB risk-reduction protocol in those whose results indicated an increased risk of sPTB would reduce the likelihood of sPTB and its sequelae. STUDY DESIGN Prospective comparison of birth outcomes in singleton pregnancies with mid-trimester cervical length ≥2.5 cm and at otherwise low risk for sPTB randomized to undergo or not undergo mid-trimester serum proteomics screening for increased risk of sPTB (NCT03530332). Screen-positive women were offered a group of interventions aimed at reducing the risk of spontaneous PTB. The primary outcome was the rate of sPTB <37 weeks, and secondary outcomes were gestational age at delivery, total length of neonatal stay, and NICU length of stay (LOS). Unscreened and screen-negative women received standard care. The adaptive study design targeted a sample size of 3,000 to 10,000 women to detect a reduction in sPTB from 6.4 to 4.7%. Due to limited resources, the trial was stopped early prior to data unblinding. RESULTS A total of 1,191 women were randomized. Screened and unscreened women were demographically similar. sPTB <37 weeks occurred in 2.7% of screened women and 3.5% of controls (p = 0.41). In the screened compared with the unscreened group, there were no between-group differences in the gestational age at delivery, total length of neonatal stay, and NICU LOS. However, the NICU LOS among infants admitted for sPTB was significantly shorter (median = 6.8 days, interquartile range [IQR]: 1.8-8.0 vs. 45.5 days, IQR: 34.6-79.0; p = 0.005). CONCLUSION Mid-trimester serum proteomics screening of women at low risk for sPTB and the use of a sPTB risk-reduction protocol in screen-positive patients did not significantly reduce the rate of sPTB compared with women not screened, though the trial was underpowered thus limiting the interpretation of negative findings. Infants in the screened group had a significantly shorter NICU LOS, a difference likely due to a reduced number of infants in the screened group that delivered <35 weeks. KEY POINTS · Mid-trimester serum proteomics screening of women at low risk for sPTB and the use of a sPTB risk-reduction protocol in screen-positive patients did not significantly reduce the rate of sPTB, though the trial was underpowered.. · NICU LOS following sPTB was significantly shortened among women who underwent screening and risk-reduction management.. · The use of serum biomarkers may contribute to a practical strategy to reduce sPTB sequelae..
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Affiliation(s)
- D Ware Branch
- Department of Obstetrics and Gynecology, Intermountain Healthcare Maternal-Fetal Medicine and University of Utah Health, Murray, Utah
| | - John M VanBuren
- Division of Pediatric Critical Care, Department of Pediatrics, University of Utah Health, Murray, Utah
| | - T Flint Porter
- Department of Obstetrics and Gynecology, Intermountain Healthcare Maternal-Fetal Medicine and University of Utah Health, Murray, Utah
| | - Calla Holmgren
- Department of Obstetrics and Gynecology, Intermountain Healthcare Maternal-Fetal Medicine and University of Utah Health, Murray, Utah
| | - Richard Holubkov
- Division of Pediatric Critical Care, Department of Pediatrics, University of Utah Health, Murray, Utah
| | - Kent Page
- Division of Pediatric Critical Care, Department of Pediatrics, University of Utah Health, Murray, Utah
| | - Julja Burchard
- Sera Prognostics, Inc., Department of Research & Development, Salt Lake City, Utah
| | | | - M Sean Esplin
- Department of Obstetrics and Gynecology, Intermountain Healthcare Maternal-Fetal Medicine and University of Utah Health, Murray, Utah
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Burd RS, Jensen AR, VanBuren JM, Richards R, Holubkov R, Pollack MM, Berg RA, Carcillo JA, Carpenter TC, Dean JM, Gaines B, Hall MW, McQuillen PS, Meert KL, Mourani PM, Nance ML, Yates AR. Factors Associated With Functional Impairment After Pediatric Injury. JAMA Surg 2021; 156:e212058. [PMID: 34076684 DOI: 10.1001/jamasurg.2021.2058] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Importance Short- and long-term functional impairment after pediatric injury may be more sensitive for measuring quality of care compared with mortality alone. The characteristics of injured children and adolescents who are at the highest risk for functional impairment are unknown. Objective To evaluate categories of injuries associated with higher prevalence of impaired functional status at hospital discharge among children and adolescents and to estimate the number of those with injuries in these categories who received treatment at pediatric trauma centers. Design, Setting, and Participants This prospective cohort study (Assessment of Functional Outcomes and Health-Related Quality of Life After Pediatric Trauma) included children and adolescents younger than 15 years who were hospitalized with at least 1 serious injury at 1 of 7 level 1 pediatric trauma centers from March 2018 to February 2020. Exposure At least 1 serious injury (Abbreviated Injury Scale score, ≥3 [scores range from 1 to 6, with higher scores indicating more severe injury]) classified into 9 categories based on the body region injured and the presence of a severe traumatic brain injury (Glasgow Coma Scale score <9 or Glasgow Coma Scale motor score <5). Main Outcomes and Measures New domain morbidity defined as a 2 points or more change in any of 6 domains (mental status, sensory, communication, motor function, feeding, and respiratory) measured using the Functional Status Scale (FSS) (scores range from 1 [normal] to 5 [very severe dysfunction] for each domain) in each injury category at hospital discharge. The estimated prevalence of impairment associated with each injury category was assessed in the population of seriously injured children and adolescents treated at participating sites. Results This study included a sample of 427 injured children and adolescents (271 [63.5%] male; median age, 7.2 years [interquartile range, 2.5-11.7 years]), 74 (17.3%) of whom had new FSS domain morbidity at discharge. The proportion of new FSS domain morbidity was highest among those with multiple injured body regions and severe head injury (20 of 24 [83.3%]) and lowest among those with an isolated head injury of mild or moderate severity (1 of 84 [1.2%]). After adjusting for oversampling of specific injuries in the study sample, 749 of 5195 seriously injured children and adolescents (14.4%) were estimated to have functional impairment at hospital discharge. Children and adolescents with extremity injuries (302 of 749 [40.3%]) and those with severe traumatic brain injuries (258 of 749 [34.4%]) comprised the largest proportions of those estimated to have impairment at discharge. Conclusions and Relevance In this cohort study, most injured children and adolescents returned to baseline functional status by hospital discharge. These findings suggest that functional status assessments can be limited to cohorts of injured children and adolescents at the highest risk for impairment.
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Affiliation(s)
- Randall S Burd
- Division of Trauma and Burn Surgery, Children's National Medical Center, Washington, DC
| | - Aaron R Jensen
- University of California San Francisco Benioff Children's Hospital Oakland, Oakland
| | - John M VanBuren
- Department of Pediatrics, University of Utah School of Medicine, Salt Lake City
| | - Rachel Richards
- Department of Pediatrics, University of Utah School of Medicine, Salt Lake City
| | - Richard Holubkov
- Department of Pediatrics, University of Utah School of Medicine, Salt Lake City
| | - Murray M Pollack
- Department of Pediatrics, Children's National Health System and the George Washington University School of Medicine and Health Sciences, Washington, DC
| | | | - Robert A Berg
- Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Joseph A Carcillo
- Department of Critical Care Medicine and Pediatrics, Children's Hospital of Pittsburgh, Pittsburgh, Pennsylvania
| | - Todd C Carpenter
- Department of Pediatrics, Children's Hospital Colorado and University of Colorado School of Medicine, Aurora
| | - J Michael Dean
- Department of Pediatrics, University of Utah School of Medicine, Salt Lake City
| | - Barbara Gaines
- Division of Pediatric General and Thoracic Surgery, UPMC Children's Hospital of Pittsburgh, Pittsburgh, Pennsylvania
| | - Mark W Hall
- Division of Critical Care Medicine, Department of Pediatrics, Nationwide Children's Hospital, Columbus, Ohio
| | - Patrick S McQuillen
- Department of Pediatrics, Benioff Children's Hospital, University of California, San Francisco
| | - Kathleen L Meert
- Department of Pediatrics, Children's Hospital of Michigan, Wayne State University, Detroit.,Central Michigan University, Mt Pleasant
| | - Peter M Mourani
- Arkansas Children's Research Institute, Arkansas Children's Hospital, Little Rock
| | - Michael L Nance
- Division of Pediatric Trauma, Department of Surgery, College of Medicine, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Andrew R Yates
- Department of Pediatrics, Nationwide Children's Hospital, The Ohio State University, Columbus
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41
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Siems A, Banks R, Holubkov R, Meert KL, Bauerfeld C, Beyda D, Berg RA, Bulut Y, Burd RS, Carcillo J, Dean JM, Gradidge E, Hall MW, McQuillen PS, Mourani PM, Newth CJL, Notterman DA, Priestley MA, Sapru A, Wessel DL, Yates AR, Zuppa AF, Pollack MM. Structured Chart Review: Assessment of a Structured Chart Review Methodology. Hosp Pediatr 2021; 10:61-69. [PMID: 31879317 DOI: 10.1542/hpeds.2019-0225] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
BACKGROUND AND OBJECTIVES Chart reviews are frequently used for research, care assessments, and quality improvement activities despite an absence of data on reliability and validity. We aim to describe a structured chart review methodology and to establish its validity and reliability. METHODS A generalizable structured chart review methodology was designed to evaluate causes of morbidity or mortality and to identify potential therapeutic advances. The review process consisted of a 2-tiered approach with a primary review completed by a site physician and a short secondary review completed by a central physician. A total of 327 randomly selected cases of known mortality or new morbidities were reviewed. Validity was assessed by using postreview surveys with a Likert scale. Reliability was assessed by percent agreement and interrater reliability. RESULTS The primary reviewers agreed or strongly agreed in 94.9% of reviews that the information to form a conclusion about pathophysiological processes and therapeutic advances could be adequately found. They agreed or strongly agreed in 93.2% of the reviews that conclusions were easy to make, and confidence in the process was 94.2%. Secondary reviewers made modifications to 36.6% of cases. Duplicate reviews (n = 41) revealed excellent percent agreement for the causes (80.5%-100%) and therapeutic advances (68.3%-100%). κ statistics were strong for the pathophysiological categories but weaker for the therapeutic categories. CONCLUSIONS A structured chart review by knowledgeable primary reviewers, followed by a brief secondary review, can be valid and reliable.
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Affiliation(s)
- Ashley Siems
- School of Medicine and Health Sciences, The George Washington University and Children's National Health System, Washington, District of Columbia
| | - Russell Banks
- School of Medicine, University of Utah, Salt Lake City, Utah
| | | | - Kathleen L Meert
- Wayne State University and Children's Hospital of Michigan, Detroit, Michigan
| | - Christian Bauerfeld
- Wayne State University and Children's Hospital of Michigan, Detroit, Michigan
| | - David Beyda
- College of Medicine-Phoenix, University of Arizona and Phoenix Children's Hospital, Phoenix, Arizona
| | - Robert A Berg
- Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Yonca Bulut
- University of California, Los Angeles and University of California, Los Angeles Mattel Children's Hospital, California
| | - Randall S Burd
- School of Medicine and Health Sciences, The George Washington University and Children's National Health System, Washington, District of Columbia
| | - Joseph Carcillo
- University of Pittsburgh Medical Center Children's Hospital of Pittsburgh, Pittsburgh, Pennsylvania
| | - J Michael Dean
- School of Medicine, University of Utah, Salt Lake City, Utah
| | - Eleanor Gradidge
- College of Medicine-Phoenix, University of Arizona and Phoenix Children's Hospital, Phoenix, Arizona
| | - Mark W Hall
- Nationwide Children's Hospital, Columbus, Ohio
| | - Patrick S McQuillen
- University of California, San Francisco and University of California, San Francisco Benioff Children's Hospital, San Francisco, California
| | - Peter M Mourani
- University of Colorado and Children's Hospital of Colorado, Denver, Colorado
| | - Christopher J L Newth
- Keck School of Medicine, University of Southern California and Children's Hospital Los Angeles, Los Angeles, California; and
| | | | | | - Anil Sapru
- University of California, Los Angeles and University of California, Los Angeles Mattel Children's Hospital, California
| | - David L Wessel
- School of Medicine and Health Sciences, The George Washington University and Children's National Health System, Washington, District of Columbia
| | | | - Athena F Zuppa
- Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Murray M Pollack
- School of Medicine and Health Sciences, The George Washington University and Children's National Health System, Washington, District of Columbia;
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Barnard ND, Kahleova H, Holtz DN, del Aguila F, Neola M, Crosby LM, Holubkov R. The Women's Study for the Alleviation of Vasomotor Symptoms (WAVS): a randomized, controlled trial of a plant-based diet and whole soybeans for postmenopausal women. Menopause 2021; 28:1150-1156. [PMID: 34260478 PMCID: PMC8462449 DOI: 10.1097/gme.0000000000001812] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2021] [Revised: 04/08/2021] [Accepted: 04/08/2021] [Indexed: 11/26/2022]
Abstract
OBJECTIVE This study aimed to assess the effects of the combination of a low-fat plant-based diet and soybeans on the frequency and severity of menopausal hot flashes. METHODS Postmenopausal women (n = 38) reporting two or more hot flashes/day were randomly assigned to a low-fat, vegan diet, including ½ cup (86 g) of cooked soybeans daily, or to no diet changes for 12 weeks. Frequency and severity of hot flashes were recorded using a mobile application, and vasomotor, psychosocial, physical, and sexual symptoms were assessed using the Menopause-Specific Quality of Life Questionnaire. Significance was assessed using t-tests (continuous outcomes) and chi-squared/McNemar tests (binary outcomes). RESULTS Total hot flashes decreased 79% in the intervention group (P < 0.001) and 49% in the control group (P = 0.002; between-group P = 0.01). Moderate-to-severe hot flashes decreased 84% in the intervention group (P < 0.001) and 42% in the control group P = 0.009; between-group P = 0.01). From 0 to 12 weeks, 59% (10/17) of intervention-group participants reported becoming free of moderate and severe hot flashes (P = 0.002). There was no change in this variable in the control group (between-group P < 0.001). The Menopause-Specific Quality of Life Questionnaire revealed significantly greater reductions in the intervention group in vasomotor (P < 0.0001), psychosocial (P = 0.04), physical (P < 0.002), and sexual (P = 0.01) domains. CONCLUSIONS The combination of a low-fat, vegan diet and whole soybeans was associated with reduced frequency and severity of hot flashes and improved quality of life in vasomotor, psychosocial, physical, and sexual domains in postmenopausal women. During the 12-week study period, the majority of intervention-group participants became free of moderate-to-severe hot flashes.
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Affiliation(s)
- Neal D. Barnard
- Physicians Committee for Responsible Medicine, Washington, DC
- Adjunct Faculty, George Washington University School of Medicine, Washington, DC
| | - Hana Kahleova
- Physicians Committee for Responsible Medicine, Washington, DC
| | | | | | - Maggie Neola
- Physicians Committee for Responsible Medicine, Washington, DC
| | - Lelia M. Crosby
- Physicians Committee for Responsible Medicine, Washington, DC
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Abstract
OBJECTIVE To examine children's unmet and unrecognized healthcare and school needs following traumatic brain injury (TBI). SETTING Two pediatric trauma centers. PARTICIPANTS Children with all severity of TBI aged 4 to 15 years. DESIGN Prospective cohort. MAIN MEASURES Caregivers provided child health and school service use 3 and 12 months postinjury. Unmet and unrecognized needs were categorized compared with norms on standardized physical, cognitive, socioemotional health, or academic competence measures in conjunction with caregiver report of needs and services. Modified Poisson models examined child and family predictors of unmet and unrecognized needs. RESULTS Of 322 children, 28% had unmet or unrecognized healthcare or school needs at 3 months, decreasing to 24% at 12 months. Unmet healthcare needs changed from primarily physical (79%) at 3 months to cognitive (47%) and/or socioemotional needs (68%) at 12 months. At 3 months, low social capital, preexisting psychological diagnoses, and 6 to 11 years of age predicted higher healthcare needs and severe TBI predicted higher school needs. Twelve months postinjury, prior inpatient rehabilitation, low income, and preexisting psychological diagnoses were associated with higher healthcare needs; family function was important for school and healthcare needs. CONCLUSIONS Targeted interventions to provide family supports may increase children's access to services.
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Affiliation(s)
- Heather T Keenan
- Division of Critical Care, Department of Pediatrics, The University of Utah, Salt Lake City (Drs Keenan and Holubkov and Ms Clark); and Department of Pediatrics and Children's Learning Institute, University of Texas McGovern Medical School, Houston (Dr Ewing-Cobbs)
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Ewing-Cobbs L, Montroy JJ, Clark AE, Holubkov R, Cox CS, Keenan HT. As Time Goes by: Understanding Child and Family Factors Shaping Behavioral Outcomes After Traumatic Brain Injury. Front Neurol 2021; 12:687740. [PMID: 34290664 PMCID: PMC8287068 DOI: 10.3389/fneur.2021.687740] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2021] [Accepted: 05/25/2021] [Indexed: 11/13/2022] Open
Abstract
Objective: To model pre-injury child and family factors associated with the trajectory of internalizing and externalizing behavior problems across the first 3 years in children with pediatric traumatic brain injury (TBI) relative to children with orthopedic injuries (OI). Parent-reported emotional symptoms and conduct problems were expected to have unique and shared predictors. We hypothesized that TBI, female sex, greater pre-injury executive dysfunction, adjustment problems, lower income, and family dysfunction would be associated with less favorable outcomes. Methods: In a prospective longitudinal cohort study, we examined the level of behavior problems at 12 months after injury and rate of change from pre-injury to 12 months and from 12 to 36 months in children ages 4–15 years with mild to severe TBI relative to children with OI. A structural equation model framework incorporated injury characteristics, child demographic variables, as well as pre-injury child reserve and family attributes. Internalizing and externalizing behavior problems were indexed using the parent-rated Emotional Symptoms and Conduct Problems scales from the Strengths and Difficulties questionnaire. Results: The analysis cohort of 534 children [64% boys, M (SD) 8.8 (4.3) years of age] included 395 with mild to severe TBI and 139 with OI. Behavior ratings were higher after TBI than OI but did not differ by TBI severity. TBI, higher pre-injury executive dysfunction, and lower income predicted the level and trajectory of both Emotional Symptoms and Conduct Problems at 12 months. Female sex and poorer family functioning were vulnerability factors associated with greater increase and change in Emotional Symptoms by 12 months after injury; unique predictors of Conduct Problems included younger age and prior emotional/behavioral problems. Across the long-term follow-up from 12 to 36 months, Emotional Symptoms increased significantly and Conduct Problems stabilized. TBI was not a significant predictor of change during the chronic stage of recovery. Conclusions: After TBI, Emotional Symptoms and Conduct Problem scores were elevated, had different trajectories of change, increased or stayed elevated from 12 to 36 months after TBI, and did not return to pre-injury levels across the 3 year follow-up. These findings highlight the importance of addressing behavioral problems after TBI across an extended time frame.
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Affiliation(s)
- Linda Ewing-Cobbs
- Department of Pediatrics and Children's Learning Institute, McGovern Medical School, University of Texas Health Science Center at Houston, Houston, TX, United States
| | - Janelle J Montroy
- Department of Pediatrics and Children's Learning Institute, McGovern Medical School, University of Texas Health Science Center at Houston, Houston, TX, United States
| | - Amy E Clark
- Department of Pediatrics, Division of Critical Care, School of Medicine, University of Utah, Salt Lake City, UT, United States
| | - Richard Holubkov
- Department of Pediatrics, Division of Critical Care, School of Medicine, University of Utah, Salt Lake City, UT, United States
| | - Charles S Cox
- Department of Pediatric Surgery, McGovern Medical School, University of Texas Health Science Center at Houston, Houston, TX, United States
| | - Heather T Keenan
- Department of Pediatrics, Division of Critical Care, School of Medicine, University of Utah, Salt Lake City, UT, United States
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Strahle JM, Mahaney KB, Morales DM, Buddhala C, Shannon CN, Wellons JC, Kulkarni AV, Jensen H, Reeder RW, Holubkov R, Riva-Cambrin JK, Whitehead WE, Rozzelle CJ, Tamber M, Pollack IF, Naftel RP, Kestle JRW, Limbrick DD. Longitudinal CSF Iron Pathway Proteins in Posthemorrhagic Hydrocephalus: Associations with Ventricle Size and Neurodevelopmental Outcomes. Ann Neurol 2021; 90:217-226. [PMID: 34080727 DOI: 10.1002/ana.26133] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2021] [Revised: 04/27/2021] [Accepted: 05/15/2021] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Iron has been implicated in the pathogenesis of brain injury and hydrocephalus after preterm germinal matrix hemorrhage-intraventricular hemorrhage, however, it is unknown how external or endogenous intraventricular clearance of iron pathway proteins affect the outcome in this group. METHODS This prospective multicenter cohort included patients with posthemorrhagic hydrocephalus (PHH) who underwent (1) temporary and permanent cerebrospinal fluid (CSF) diversion and (2) Bayley Scales of Infant Development-III testing around 2 years of age. CSF proteins in the iron handling pathway were analyzed longitudinally and compared to ventricle size and neurodevelopmental outcomes. RESULTS Thirty-seven patients met inclusion criteria with a median estimated gestational age at birth of 25 weeks; 65% were boys. Ventricular CSF levels of hemoglobin, iron, total bilirubin, and ferritin decreased between temporary and permanent CSF diversion with no change in CSF levels of ceruloplasmin, transferrin, haptoglobin, and hepcidin. There was an increase in CSF hemopexin during this interval. Larger ventricle size at permanent CSF diversion was associated with elevated CSF ferritin (p = 0.015) and decreased CSF hemopexin (p = 0.007). CSF levels of proteins at temporary CSF diversion were not associated with outcome, however, higher CSF transferrin at permanent CSF diversion was associated with improved cognitive outcome (p = 0.015). Importantly, longitudinal change in CSF iron pathway proteins, ferritin (decrease), and transferrin (increase) were associated with improved cognitive (p = 0.04) and motor (p = 0.03) scores and improved cognitive (p = 0.04), language (p = 0.035), and motor (p = 0.008) scores, respectively. INTERPRETATION Longitudinal changes in CSF transferrin (increase) and ferritin (decrease) are associated with improved neurodevelopmental outcomes in neonatal PHH, with implications for understanding the pathogenesis of poor outcomes in PHH. ANN NEUROL 2021;90:217-226.
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Affiliation(s)
- Jennifer M Strahle
- Department of Neurosurgery, Washington University St. Louis, St. Louis, MO, USA
| | - Kelly B Mahaney
- Department of Neurosurgery, Stanford University, Palo Alto, CA, USA
| | - Diego M Morales
- Department of Neurosurgery, Washington University St. Louis, St. Louis, MO, USA
| | - Chandana Buddhala
- Department of Neurosurgery, Washington University St. Louis, St. Louis, MO, USA
| | - Chevis N Shannon
- Department of Neurosurgery, Vanderbilt University Medical Center, Nashville, TN, USA
| | - John C Wellons
- Department of Neurosurgery, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Abhaya V Kulkarni
- Department of Neurosurgery, University of Toronto, Toronto, Ontario, Canada
| | - Hailey Jensen
- Data Coordinating Center, University of Utah, Salt Lake City, UT, USA
| | - Ron W Reeder
- Data Coordinating Center, University of Utah, Salt Lake City, UT, USA
| | - Richard Holubkov
- Data Coordinating Center, University of Utah, Salt Lake City, UT, USA
| | - Jay K Riva-Cambrin
- Department of Clinical Neurosciences, University of Calgary, Calgary, Alberta, Canada
| | | | - Curtis J Rozzelle
- Department of Neurosurgery, University of Alabama - Birmingham, Birmingham, AL, USA
| | - Mandeep Tamber
- Department of Surgery, University of British Columbia, Vancouver, British Columbia, Canada
| | - Ian F Pollack
- Department of Neurosurgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Robert P Naftel
- Department of Neurosurgery, Vanderbilt University Medical Center, Nashville, TN, USA
| | - John R W Kestle
- Department of Neurosurgery, University of Utah, Salt Lake City, UT, USA
| | - David D Limbrick
- Department of Neurosurgery, Washington University St. Louis, St. Louis, MO, USA
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Kahleova H, McCann J, Alwarith J, Rembert E, Tura A, Holubkov R, Barnard ND. A plant-based diet in overweight adults in a 16-week randomized clinical trial: The role of dietary acid load. Clin Nutr ESPEN 2021; 44:150-158. [PMID: 34330460 DOI: 10.1016/j.clnesp.2021.05.015] [Citation(s) in RCA: 25] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2020] [Revised: 04/02/2021] [Accepted: 05/17/2021] [Indexed: 10/21/2022]
Abstract
BACKGROUND Evidence suggests that changes in dietary acid load may influence body weight, body composition, and insulin sensitivity. METHODS Participants (n = 244) were randomly assigned to an intervention (vegan) (n = 122) or control group (n = 122) for 16 weeks. Before and after the intervention period, body composition was measured by dual X-ray absorptiometry. Insulin resistance was assessed with the Homeostasis Model Assessment (HOMA-IR) index and predicted insulin sensitivity index (PREDIM). Repeated measure ANOVA was used for statistical analysis. RESULTS Potential Renal Acid Load (PRAL) and Net Endogenous Acid Production (NEAP) decreased significantly in the vegan group with no change in the control group (treatment effect -24.7 mEq/day [95% CI -30.2 to -19.2]; p < 0.001; and -23.8 mEq/day [95% CI -29.6 to -18.0]; p < 0.001, respectively). Body weight decreased by 6.4 kg in the vegan group, compared with 0.5 kg in the control group (treatment effect -5.9 kg [95% CI -6.8 to -5.0]; Gxt, p < 0.001), largely due to a reduction in fat mass and visceral fat. HOMA-IR index decreased and PREDIM increased in the vegan group. After adjustment for energy intake, changes in PRAL and NEAP correlated positively with changes in body weight (r = +0.37; p < 0.001; and r = +0.37; p < 0.001, respectively), fat mass (r = +0.32; p < 0.001; and r = +0.32; p < 0.001, respectively), visceral fat (r = +0.19; p = 0.006; and r = +0.15; p = 0.03, respectively), and HOMA (r = +0.17; p = 0.02; and r = +0.20; p = 0.006, respectively), and negatively with changes in PREDIM (r = -0.22; p = 0.002; and r = -0.27; p < 0.001, respectively). CONCLUSION Dietary acid load as part of a plant-based diet was associated with changes in body weight, body composition, and insulin sensitivity, independent of energy intake. Mechanistic explanations suggest that the relationship may be causal. TRIAL REGISTRATION ClinicalTrials.gov number, NCT03698955.
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Affiliation(s)
- Hana Kahleova
- Physicians Committee for Responsible Medicine, Washington, DC, USA.
| | - James McCann
- Physicians Committee for Responsible Medicine, Washington, DC, USA
| | - Jihad Alwarith
- Physicians Committee for Responsible Medicine, Washington, DC, USA
| | - Emilie Rembert
- Physicians Committee for Responsible Medicine, Washington, DC, USA
| | - Andrea Tura
- Metabolic Unit, CNR Institute of Neuroscience, Padua, Italy
| | | | - Neal D Barnard
- Physicians Committee for Responsible Medicine, Washington, DC, USA; Adjunct Faculty, George Washington University School of Medicine and Health Sciences, Washington, DC, USA
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Suttle M, Hall MW, Pollack MM, Berg RA, McQuillen PS, Mourani PM, Sapru A, Carcillo JA, Startup E, Holubkov R, Dean JM, Notterman DA, Meert KL. The Association between Therapeutic Alliance and Parental Health Outcomes following a Child's Death in the Pediatric Intensive Care Unit. J Pediatr Intensive Care 2021; 12:3-11. [PMID: 36742250 PMCID: PMC9894698 DOI: 10.1055/s-0041-1727179] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2020] [Accepted: 02/20/2021] [Indexed: 02/07/2023] Open
Abstract
Therapeutic alliance reflects the strength and quality of the physician-patient/family relationship. We investigated the association between therapeutic alliance and bereaved parents' mental health and perceived overall health following their child's death in a pediatric intensive care unit (PICU). Bereaved parents were surveyed 6 months after their child's death in a PICU affiliated with the Collaborative Pediatric Critical Care Research Network. Parents were evaluated for complicated grief, depression, and post-traumatic stress using the Inventory of Complicated Grief (ICG), the Patient Health Questionnaire (PHQ-8), and the Short Post-Traumatic Stress Disorder Rating Interview (SPRINT), respectively. Overall health was evaluated using a single item. Therapeutic alliance between parents and their deceased child's PICU physicians was assessed using the Human Connection scale (HCS). Two hundred and thirty-five parents of 158 deceased children completed surveys. Mean ICG score was 34.4 ± 14.9 with 142 (60.4%) parents screening positive for complicated grief. Mean PHQ-8 score was 9.1 ± 6.2 with 102 (43.4%) screening positive for at least moderate depression. Mean SPRINT score was 14.6 ± 8.2 with 122 (51.9%) screening positive for post-traumatic stress disorder. Overall health was perceived as fair for 47 (20.0%) parents and poor for 10 (4.3%). Using multivariable modeling, higher HCS score (greater therapeutic alliance) was significantly associated with lower (better) ICG score (-0.23, 95% CI -0.42, -0.04, p = 0.018). HCS score was not significantly associated with PHQ-8, SPRINT, or overall health scores. We conclude that bereaved parents experience a high level of adverse mental health symptoms including complicated grief, depression, and post-traumatic stress symptoms. Greater therapeutic alliance with PICU physicians may lessen symptoms of complicated grief during bereavement.
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Affiliation(s)
- Markita Suttle
- Department of Pediatrics, Nationwide Children's Hospital, Columbus, Ohio, United States
| | - Mark W. Hall
- Department of Pediatrics, Nationwide Children's Hospital, Columbus, Ohio, United States
| | - Murray M. Pollack
- Department of Pediatrics, Children's National Hospital, Washington, United States
| | - Robert A. Berg
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia, Pennsylvania, United States
| | - Patrick S. McQuillen
- Department of Pediatrics, Benioff Children's Hospital, University of California, San Francisco, San Francisco, California, United States
| | - Peter M. Mourani
- Department of Pediatrics, Children's Hospital of Colorado, University of Colorado School of Medicine, Colorado, United States
| | - Anil Sapru
- Department of Pediatrics, Mattel Children's Hospital, University of California Los Angeles, California, United States
| | - Joseph A. Carcillo
- Department of Critical Care Medicine, Children's Hospital of Pittsburgh, University of Pittsburgh Medical Center, Pennsylvania, United States
| | - Emily Startup
- Department of Pediatrics, University of Utah, Salt Lake City, Utah, United States
| | - Richard Holubkov
- Department of Pediatrics, University of Utah, Salt Lake City, Utah, United States
| | | | - Daniel A. Notterman
- Department of Molecular Biology, Princeton University, New Jersey, United States
| | - Kathleen L. Meert
- Department of Pediatrics, Children's Hospital of Michigan, Detroit, MI, Central Michigan University, Mt. Pleasant, Michigan, United States,Address for correspondence Kathleen L. Meert, MD Division of Pediatric Critical Care Medicine, Children's Hospital of Michigan3901 Beaubien, Detroit, MI 48201United States
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Suttle M, Hall MW, Pollack MM, Berg RA, McQuillen PS, Mourani PM, Sapru A, Carcillo JA, Startup E, Holubkov R, Dean JM, Notterman DA, Meert KL. Complicated Grief, Depression and Post-Traumatic Stress Symptoms Among Bereaved Parents following their Child's Death in the Pediatric Intensive Care Unit: A Follow-Up Study. Am J Hosp Palliat Care 2021; 39:228-236. [PMID: 33949217 PMCID: PMC10184266 DOI: 10.1177/10499091211015913] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023] Open
Abstract
BACKGROUND Parents often suffer reduced mental health after their child's death; however, the trajectory and risk factors are not well described. OBJECTIVE Describe the change in complicated grief, depression, and post-traumatic stress symptoms among parents between 6 and 13 months after their child's death in a pediatric intensive care unit (PICU), and factors associated with 13-month symptoms. METHODS Parents whose children died in 1 of 8 PICUs affiliated with the Collaborative Pediatric Critical Care Research Network completed surveys 6 and 13 months after their child's death. Surveys included the Inventory of Complicated Grief (ICG), the Patient Health Questionnaire-8 (PHQ-8) for depression, and the Short Post-Traumatic Stress Disorder Rating Interview (SPRINT). Parents provided sociodemographics. Charts were reviewed for child characteristics. RESULTS One-hundred and fifty seven parents of 104 deceased children completed surveys at both time points. Mental health symptoms declined over time (mean (SD)): ICG (33.8 (15.4) vs. 30.5 (15.2), p < 0.001), PHQ-8 (9.0 (6.4) vs. 7.3 (5.8), p < 0.001), and SPRINT (14.1 (8.3) vs. 12.0 (8.2), p < 0.001). After controlling for 6-month scores, higher 13-month ICG was independently associated with sudden unexpected death; higher PHQ-8 with Black race, insecure attachment style, and sudden unexpected death; and higher SPRINT with having a high school level of education (compared to college degree or higher). CONCLUSION Mental health symptoms improve among parents during the first 13 months after their child's death; however, symptoms persist for many. Black parents and those whose children die suddenly may be high risk for poor adjustment during bereavement.
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Affiliation(s)
- Markita Suttle
- Department of Pediatrics, Nationwide Children's Hospital, Columbus, OH, USA)
| | - Mark W Hall
- Department of Pediatrics, Nationwide Children's Hospital, Columbus, OH, USA)
| | - Murray M Pollack
- Department of Pediatrics, Children's National Hospital, Washington DC, USA
| | - Robert A Berg
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Patrick S McQuillen
- Department of Pediatrics, Benioff Children's Hospital, University of California, San Francisco, San Francisco, CA, USA
| | - Peter M Mourani
- Department of Pediatrics, Children's Hospital of Colorado, University of Colorado School of Medicine, Aurora, CO, USA
| | - Anil Sapru
- Department of Pediatrics, Mattel Children's Hospital, University of California Los Angeles, Los Angeles, CA, USA
| | - Joseph A Carcillo
- Department of Critical Care Medicine, Children's Hospital of Pittsburgh, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Emily Startup
- Department of Pediatrics, University of Utah, Salt Lake City, UT, USA
| | - Richard Holubkov
- Department of Pediatrics, University of Utah, Salt Lake City, UT, USA
| | - J Michael Dean
- Department of Pediatrics, University of Utah, Salt Lake City, UT, USA
| | - Daniel A Notterman
- Department of Molecular Biology, Princeton University, Princeton, NJ, USA
| | - Kathleen L Meert
- Department of Pediatrics, Children's Hospital of Michigan, Detroit, MI, Central Michigan University, Mt. Pleasant, MI, USA
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Meert KL, Reeder RW, Maddux AB, Banks R, Berg RA, Newth CJ, Hall MW, Quasney M, Carcillo JA, McQuillen PS, Mourani PM, Chima RS, Holubkov R, Sorenson S, McGalliard J, Dean JM, Zimmerman JJ. Health-Related Quality of Life After Community-Acquired Septic Shock in Children With Preexisting Severe Developmental Disabilities. Pediatr Crit Care Med 2021; 22:e302-e313. [PMID: 33156209 PMCID: PMC8099927 DOI: 10.1097/pcc.0000000000002606] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
OBJECTIVES To serially evaluate health-related quality of life during the first year after community-acquired septic shock in children with preexisting severe developmental disabilities and explore factors associated with health-related quality of life changes in these children. DESIGN Secondary analysis of the Life after Pediatric Sepsis Evaluation investigation. SETTING Twelve academic PICU in the United States. PATIENTS Children greater than or equal to 1 month and less than 18 years old identified by their family caregiver (e.g., parent/guardian) as having severe developmental disability prior to septic shock. INTERVENTIONS Family caregivers completed the Stein-Jessop Functional Status II-R Short Form as a measure of their child's health-related quality of life at baseline (reflecting preadmission status), day 7, and months 1, 3, 6, and 12 following PICU admission. Stein-Jessop Functional Status II-R Short Form scores were linearly transformed to a 0-100 scale, with higher scores indicating better health-related quality of life. MEASUREMENTS AND MAIN RESULTS Of 392 Life after Pediatric Sepsis Evaluation participants, 137 were identified by their caregiver as having a severe developmental disability. Sixteen children (11.6%) with severe disability died during the 12 months following septic shock. Among 121 survivors, Stein-Jessop Functional Status II-R Short Form scores declined from preadmission baseline to day 7 (70.7 ± 16.1 vs 55.6 ± 19.2; p < 0.001). Stein-Jessop Functional Status II-R Short Form scores remained below baseline through month 12 (59.1 ± 21.0, p < 0.001 vs baseline). After adjusting for baseline Stein-Jessop Functional Status II-R Short Form, the caregiver being a single parent/guardian was associated with lower month 3 Stein-Jessop Functional Status II-R Short Form scores (p = 0.041). No other baseline child or caregiver characteristic, or critical illness-related factors were significantly associated with month 3 Stein-Jessop Functional Status II-R Short Form scores. CONCLUSIONS Health-related quality of life among children with severe developmental disability remains, on average, below baseline during the first year following community-acquired septic shock. Children with severe disability and septic shock that are in single parent families are at increased risk. Clinical awareness of the potential for decline in health-related quality of life among disabled children is essential to prevent this adverse outcome from being missed.
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Affiliation(s)
- Kathleen L. Meert
- Department of Pediatrics, Children's Hospital of Michigan, Central Michigan University, Detroit, MI
| | - Ron W. Reeder
- Department of Pediatrics, University of Utah, Salt Lake City, UT
| | - Aline B. Maddux
- Department of Pediatrics, Children’s Hospital of Colorado, University of Colorado School of Medicine, Aurora, CO
| | - Russell Banks
- Department of Pediatrics, University of Utah, Salt Lake City, UT
| | - Robert A. Berg
- Department of Anesthesiology and Critical Care Medicine, Children’s Hospital of Philadelphia, Philadelphia, PA
| | - Christopher J. Newth
- Department of Anesthesiology Critical Care Medicine, Children’s Hospital Los Angeles, Los Angeles, CA
| | - Mark W. Hall
- Department of Pediatrics, Nationwide Children’s Hospital, Columbus, OH
| | - Michael Quasney
- Department of Pediatrics, C.S. Mott Children’s Hospital, University of Michigan, Ann Arbor, MI
| | - Joseph A. Carcillo
- Department of Critical Care Medicine, Children’s Hospital of Pittsburgh, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Patrick S. McQuillen
- Department of Pediatrics, Benioff Children’s Hospital, University of California, San Francisco, San Francisco, CA
| | - Peter M. Mourani
- Department of Pediatrics, Children’s Hospital of Colorado, University of Colorado School of Medicine, Aurora, CO
| | - Ranjit S. Chima
- Department of Pediatrics, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH
| | - Richard Holubkov
- Department of Pediatrics, University of Utah, Salt Lake City, UT
| | - Samuel Sorenson
- Department of Pediatrics, University of Utah, Salt Lake City, UT
| | - Julie McGalliard
- Center for Child Health, Behavior and Development, Seattle Children’s Hospital, Seattle Research Institute, Seattle, WA
| | - J. Michael Dean
- Department of Pediatrics, University of Utah, Salt Lake City, UT
| | - Jerry J. Zimmerman
- Department of Pediatrics, Seattle Children’s Hospital, Seattle Research Institute, University of Washington School of Medicine, Seattle, WA
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Suttle M, Hall MW, Pollack MM, Berg RA, McQuillen PS, Mourani PM, Sapru A, Carcillo JA, Startup E, Holubkov R, Dean JM, Notterman DA, Meert KL. Therapeutic Alliance Between Bereaved Parents and Physicians in the PICU. Pediatr Crit Care Med 2021; 22:e243-e252. [PMID: 33044415 PMCID: PMC8016694 DOI: 10.1097/pcc.0000000000002585] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVES Therapeutic alliance is the collaborative bond that develops between patients/families and healthcare providers. Our objective is to determine the extent of therapeutic alliance bereaved parents perceive to have occurred with their child's physicians during their child's PICU stay, and associated factors. DESIGN Multicenter observational study. SETTING Eight children's hospitals affiliated with the Collaborative Pediatric Critical Care Research Network. PATIENTS Parents greater than or equal to 18 years old whose child died in a PICU (including cardiac ICU). INTERVENTIONS Bereaved parents completed the Human Connection Scale, a 16-item measure of therapeutic alliance, 6 months after their child's death. Human Connection Scale scores range from 16 to 64 with higher scores indicating greater alliance. Parents provided sociodemographic data, and medical records were reviewed for the child's clinical characteristics. MEASUREMENTS AND MAIN RESULTS Two-hundred and thirty-three parents of 157 deceased children responded to the Human Connection Scale with greater than or equal to 80% item completion. Among parents, 146 (62.7%) were female, 155 (66.5%) were White and 46 (19.7%) were Black, 175 (75.1%) were married, and 209 (89.7%) had at least a high-school education. Among children, median age at the time of death was 5.9 years (interquartile range, 0.64-13.9 yr) and 114 (72.6%) died after limitation or withdrawal of life support. Mean Human Connection Scale score was 51.4 ± 11.1 for all parents, 52.6 ± 9.0 for White parents, and 47.0 ± 13.7 for Black parents. In multivariable modeling predicting Human Connection Scale scores, race was the only parent or child characteristic in the final model. Human Connection Scale scores were significantly different (-4.56; 95% CI, -8.53 to -0.6; p = 0.025) between the Black and White parents with items about trust, care, and honest communication showing the greatest mean difference. CONCLUSIONS Among parents bereaved in the PICU, therapeutic alliance with physicians is moderately high. Future research should identify strategies to strengthen therapeutic alliance with Black parents and examine the role of alliance on bereaved parents' health outcomes.
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Affiliation(s)
- Markita Suttle
- Department of Pediatrics, Nationwide Children’s Hospital, Columbus, OH
| | - Mark W. Hall
- Department of Pediatrics, Nationwide Children’s Hospital, Columbus, OH
| | - Murray M. Pollack
- Department of Pediatrics, Children’s National Hospital, Washington DC
| | - Robert A. Berg
- Department of Anesthesiology and Critical Care Medicine, Children’s Hospital of Philadelphia, Philadelphia, PA
| | - Patrick S. McQuillen
- Department of Pediatrics, Benioff Children’s Hospital, University of California, San Francisco, San Francisco, CA
| | - Peter M. Mourani
- Department of Pediatrics, Children’s Hospital of Colorado, University of Colorado School of Medicine, Aurora, CO
| | - Anil Sapru
- Department of Pediatrics, Mattel Children’s Hospital, University of California Los Angeles, Los Angeles, CA
| | - Joseph A. Carcillo
- Department of Critical Care Medicine, Children’s Hospital of Pittsburgh, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Emily Startup
- Department of Pediatrics, University of Utah, Salt Lake City, UT
| | - Richard Holubkov
- Department of Pediatrics, University of Utah, Salt Lake City, UT
| | - J. Michael Dean
- Department of Pediatrics, University of Utah, Salt Lake City, UT
| | | | - Kathleen L. Meert
- Department of Pediatrics, Children’s Hospital of Michigan, Central Michigan University, Detroit, MI
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