Background Acute kidney injury (AKI) has been characterized in high-risk pediatric hospital inpatients, in whom AKI is frequent and associated with increased mortality, morbidity, and length of stay. ...The incidence of AKI among patients not requiring intensive care is unknown. Study Design Retrospective cohort study. Setting & Participants 13,914 noncritical admissions during 2011 and 2012 at our tertiary referral pediatric hospital were evaluated. Patients younger than 28 days or older than 21 years of age or with chronic kidney disease (CKD) were excluded. Admissions with 2 or more serum creatinine measurements were evaluated. Factors Demographic features, laboratory measurements, medication exposures, and length of stay. Outcome AKI defined as increased serum creatinine level in accordance with KDIGO (Kidney Disease: Improving Global Outcomes) criteria. Based on time of admission, time interval requirements were met in 97% of cases, but KDIGO time window criteria were not strictly enforced to allow implementation using clinically obtained data. Results 2 or more creatinine measurements (one baseline before or during admission and a second during admission) in 2,374 of 13,914 (17%) patients allowed for AKI evaluation. A serum creatinine difference ≥0.3 mg/dL or ≥1.5 times baseline was seen in 722 of 2,374 (30%) patients. A minimum of 5% of all noncritical inpatients without CKD in pediatric wards have an episode of AKI during routine hospital admission. Limitations Urine output, glomerular filtration rate, and time interval criteria for AKI were not applied secondary to study design and available data. The evaluated cohort was restricted to patients with 2 or more clinically obtained serum creatinine measurements, and baseline creatinine level may have been measured after the AKI episode. Conclusions AKI occurs in at least 5% of all noncritically ill hospitalized children, adolescents, and young adults without known CKD. Physicians should increase their awareness of AKI and improve surveillance strategies with serum creatinine measurements in this population so that exacerbating factors such as nephrotoxic medication exposures may be modified as indicated.
Introduction Previous studies have examined the impact of healthy lifestyle choices on health-related outcomes; however, given their fragmented, often cross-sectional nature, assessing the relative ...impact of daily modifiable behaviors on overall long-term outcomes, particularly for a diverse working adult population, remains challenging. Methods Relationships between ten self-reported healthy lifestyle behaviors and health outcomes during the subsequent 9 years in a cohort of 10,248 participants enrolled during 2003 in a voluntary workplace wellness program were assessed. Cox proportional-hazards models computed hazard ratios (HRs) for lifestyle characteristics associated with time to one of seven self-reported chronic diseases or death. Data were collected between 2003 and 2012 and analyzed between 2014 and 2016. Results Behaviors that most significantly affected future outcomes were low-fat diet, aerobic exercise, nonsmoking, and adequate sleep. A dose–response effect was seen between dietary fat intake and hypertension, obesity, diabetes, heart disease, and hypercholesterolemia. After dietary fat intake, aerobic exercise was the next most significant behavior associated with development of outcomes. Compared with sedentary participants, those who exercised 4 days per week were less likely to develop new-onset diabetes (HR=0.31, 95% CI=0.20, 0.48); heart disease (HR=0.46, 95% CI=0.27, 0.80); and hypercholesterolemia (HR=0.61, 95% CI=0.50, 0.74). Low-fat diet and adequate sleep were more significant than commonly promoted healthy behaviors, such as eating a daily breakfast. Conclusions Modifiable lifestyle behaviors targeted in health promotion programs should be prioritized in an evidence-based manner. Top priorities for workplace health promotion should include low-fat diet, aerobic exercise, nonsmoking, and adequate sleep.
Background Antibody response to the inactivated influenza vaccine is not well described in kidney transplant recipients administered newer, but commonly used, immunosuppression medications. We ...hypothesized that kidney transplant recipient participants administered tacrolimus-based regimens would have decreased antibody response compared with healthy controls. Study Design Prospective cohort study of 53 kidney transplant recipients and 106 healthy control participants during the 2006-2007 influenza season. All participants received standard inactivated influenza vaccine. Setting & Participants Kidney transplant recipients administered tacrolimus-based regimens at a single academic medical center and healthy controls. Predictor Presence of kidney transplant. Outcomes Proportion of participants achieving seroresponse (4-fold increase in antibody titer) and seroprotection (antibody titer ≥ 1:32) 1 month after vaccination. Measurements Antibody titers before and 1 month after vaccination by means of hemagglutinin inhibition assays for influenza types A/H1N1, A/H3N2, and B. Results A smaller proportion of the transplantation group compared with the healthy control group developed the primary outcomes of seroresponse or seroprotection for all 3 influenza types at 1 month after vaccination. The response to influenza type A/H3N2 was statistically different; the transplantation group had 69% decreased odds of developing seroresponse (95% confidence interval, 0.16 to 0.62; P = 0.001) and 78% decreased odds of developing seroprotection (95% confidence interval, 0.09 to 0.53; P = 0.001) compared with healthy controls. When participants less than 6 months from the time of transplantation were considered, this group had a significantly decreased response to the vaccine compared with healthy controls. Limitations Decreased sample size, potential for confounders, outcome measure used is the standard but does not give information about vaccine efficacy. Conclusions Kidney transplant recipients, especially within 6 months of transplantation, had diminished antibody response to the 2006-2007 inactivated influenza vaccine.
Background Acute care nurse practitioners (ACNPs) are increasingly being employed in ICUs to offset physician shortages, but no data exist about outcomes of critically ill patients continuously cared ...for by ACNPs. Methods Prospective cohort study of all admissions to an adult medical ICU in an academic, tertiary-care center between January 1, 2011, and December 31, 2013. The primary end point of 90-day survival was compared between patients cared for by ACNP and resident teams using Cox proportional hazards regression. Secondary end points included ICU and hospital mortality and ICU and hospital length of stay. Results Among 9,066 admissions, there was no difference in 90-day survival for patients cared for by ACNP or resident teams (adjusted hazard ratio HR, 0.94; 95% CI, 0.85-1.04; P = .21). Although patients cared for by ACNPs had lower ICU mortality (6.3%) than resident team patients (11.6%; adjusted OR, 0.77; 95% CI, 0.63-0.94; P = .01), hospital mortality was not different (10.0% vs 15.9%; adjusted OR, 0.87; 95% CI, 0.73-1.03; P = .11). ICU length of stay was similar between the ACNP and resident teams (3.4 ± 3.5 days vs 3.7 ± 3.9 days adjusted OR, 1.01; 95% CI, 0.93-1.1; P = .81), but hospital length of stay was shorter for patients cared for by ACNPs (7.9 ± 11.2 days) than for resident patients (9.1 ± 11.2 days) (adjusted OR, 0.87; 95% CI, 0.80-0.95; P = .001). Conclusion Outcomes are comparable for critically ill patients cared for by ACNP and resident teams.
Background It is unknown whether preconceived beliefs regarding the need for cardiac catheterization and revascularization in patients with stable ischemic heart disease (SIHD) would preclude a study ...randomizing patients with significant ischemia to a conservative strategy. Given the widespread practice of performing revascularization in patients with SIHD, we assessed the feasibility of conducting a randomized trial comparing initial invasive and conservative strategies in patients with SIHD and moderate or severe ischemia. Methods An online survey to cardiologists queried their willingness to enroll a sample patient with frequent stable angina, >10% myocardial ischemia, and normal ejection fraction into a randomized trial with a 50% chance of being conservatively managed without cardiac catheterization. Results Among 499 respondents, 57% (95% CI 53%-62%) were willing to enroll the patient. Among 207 cardiologists unwilling to enroll, 55% (95% CI 48%-61%) would be willing if they knew the patient did not have very high-risk features on stress imaging, yielding a total of 80% (95% CI 76%-83%) of cardiologists willing to enroll. No differences were observed among different types of cardiologists (interventional, invasive/noninterventional, and noninvasive). Seventy-one percent (95% CI 67%-75%) were more likely to try initial medical therapy after the publication of the Clinical Outcomes Utilizing Revascularization and Aggressive Drug Evaluation trial results. Conclusions Most surveyed cardiologists were willing to enroll SIHD patients with at least moderate ischemia into a trial with an initial noninvasive strategy arm. These findings support the feasibility of planning a large-scale trial to test the role of cardiac catheterization and revascularization in the initial management of SIHD patients with moderate or severe ischemia.
Objective: To assess long-term changes in health risks for employees participating in Vanderbilt University's incentive-based worksite Wellness program. Methods: Descriptive longitudinal trends were ...examined for employees' health risk profiles for the period of 2003 to 2009. Results: The majority of risk factors improved over time with the most consistent change occurring in physical activity. The proportion of employees exercising one or more days per week increased from 72.7% in 2003 to 83.4% in 2009. Positive annual, monotonie changes were also observed in percentage for nonsmokers and seat belt usage. Although the largest improvements occurred between the first two years, improvements continued without significant regression toward baseline. Conclusions: This 7-year evaluation, with high participation and large sample size, provides robust estimates of health improvements that can be achieved through a voluntary incentive-based Wellness program.
Background: Basal energy requirements are higher in adolescents with sickle cell anemia (SCA) than in healthy control subjects. However, no equation is available to accurately predict their energy ...needs. Objective: Our objective was to develop a clinically useful equation to estimate resting energy expenditure (REE) in adolescents with SCA. Design: REE and other components of total energy expenditure were measured in adolescents with SCA (n = 37) and in control subjects (n = 23) for 24 h in a whole-room indirect calorimeter. Multiple linear regression analysis was used to describe the relations of REE with independent variables such as sex, weight, height, fat-free mass, fat mass, age, and hemoglobin concentration in adolescents with SCA. The Bland-Altman comparison technique was used to compare values predicted by existing equations with measured REE values. Results: Mean (+/-SD) measured REEs were 7746 +/- 974 and 6332 +/- 869 kJ/d in the male and female subjects with SCA, respectively, and these values were 16% higher than those in the healthy control subjects. Standard equations underestimated REE by 12% (P ≤ 0.001) in adolescents with SCA and overestimated REE by 4% in control subjects (P = 0.01-0.29). Several REE regression equations for SCA were developed. The most parsimonious equation for males was REE (kJ/d) = 5461 + 77.7·weight (kg) - 233.2·hemoglobin (g/dL), or REE (kcal/d) = 1305 + 18.6·weight (kg) - 55.7·hemoglobin (g/dL). For females, the most parsimonious equation was REE (kJ/d) = 4603 + 55.6·weight (kg) - 126.2·hemoglobin (g/dL), or REE (kcal/d) = 1100 + 13.3·weight (kg) - 30.2·hemoglobin (g/dL). Conclusion: The new equations have better agreement with the basal metabolic needs of adolescents with SCA than do standard predictive equations.
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