The Early Management Bundle for Severe Sepsis/Septic Shock (SEP-1) is a quality metric based on a care bundle for early sepsis management. Published evidence on the association of SEP-1 with ...mortality is mixed and largely excludes cases of hospital-onset sepsis.
To assess the association of the SEP-1 bundle with mortality and organ dysfunction in cohorts with hospital-onset or community-onset sepsis.
This retrospective cohort study used data from 4 University of California hospitals from October 1, 2014, to October 1, 2017. Adult inpatients with a diagnosis consistent with sepsis or disseminated infection and laboratory or vital signs meeting the Sepsis-3 (Third International Consensus Definitions for Sepsis and Septic Shock) criteria were divided into community-onset sepsis and hospital-onset sepsis cohorts based on whether time 0 of sepsis occurred after arrival in the emergency department or an inpatient area. Data were analyzed from April to October 2019. Additional analyses were performed from December 2019 to January 2020.
Administration of SEP-1 and 4 individual bundle components (serum lactate level testing, blood culture, broad-spectrum intravenous antibiotic treatment, and intravenous fluid treatment).
The primary outcome was in-hospital mortality. The secondary outcome was days requiring vasopressor support, measured as vasopressor days.
Among the 6404 patient encounters identified (3535 men 55.2%; mean SD age, 64.0 18.2 years), 2296 patients (35.9%) had hospital-onset sepsis. Among 4108 patients (64.1%) with community-onset sepsis, serum lactate level testing within 3 hours of time 0 was associated with reduced mortality (absolute difference, -7.61%; 95% CI, -14.70% to -0.54%). Blood culture (absolute difference, -1.10 days; 95% CI, -1.85 to -0.34 days) and broad-spectrum intravenous antibiotic treatment (absolute difference, -0.62 days; 95% CI, -1.02 to -0.22 days) were associated with fewer vasopressor days. Among patients with hospital-onset sepsis, broad-spectrum intravenous antibiotic treatment was the only bundle component significantly associated with any improved outcome (mortality difference, -5.20%; 95% CI, -9.84% to -0.56%). Care that was adherent to the complete SEP-1 bundle was associated with increased vasopressor days in patients with community-onset sepsis (absolute difference, 0.31 days; 95% CI, 0.11-0.51 days) but was not significantly associated with reduced mortality in either cohort (absolute difference, -0.07%; 95% CI, -3.02% to 2.88% in community-onset; absolute difference, -0.42%; 95% CI, -6.77% to 5.93% in hospital-onset).
SEP-1-adherent care was not associated with improved outcomes of sepsis. Although multiple components of SEP-1 were associated with reduced mortality or decreased days of vasopressor therapy for patients who presented with sepsis in the emergency department, only broad-spectrum intravenous antibiotic treatment was associated with reduced mortality when time 0 occurred in an inpatient unit. Current sepsis quality metrics may need refinement.
Schools and school climate are thought to influence academic outcomes as well as child and adolescent development, health and well-being. We sought to examine the relationship between several aspects ...of the school climate with adolescent social-emotional health outcomes.
We analysed data from the Reducing Inequities through Social and Educational change Follow-up (RISE UP) Study, a longitudinal natural experimental study of Los Angeles high school students collected from 2013 to 2018. We analysed data on the portion of the sample that completed the baseline, 10th grade and 11th grade surveys (n=1114). Students reported their perceptions of school climate at 10th grade and social-emotional outcomes including grit, self-efficacy, depression, hopelessness, and stress at baseline (9th grade) and at 11th grade. Multivariable regressions adjusted for student and parental demographics and baseline social-emotional states tested associations between school climate and each outcome.
Students who reported being in authoritative school environments in 10th grade, one that is highly supportive and highly structured, had subsequently higher levels of self-efficacy (p< 0.001) and grit (p=0.01). They also had fewer depressive symptoms (p=0.008), and less hopelessness (p = 0.01), stress at school (p=0.002) and stress about the future (p=0.03) reported in 11th grade.
School climate, and particularly an authoritative school environment, is strongly associated with better social-emotional health among adolescents. Relationship with teachers and their disciplinary style may be a focus for future interventions to improve the social-emotional health of children.
Abstract Objective Grit, defined as “working strenuously toward challenges, maintaining effort and interest over years despite failure, adversity, and plateaus in progress,” is strongly associated ...with academic achievement and life success and may also be associated with health outcomes and behaviors. We examined predictors of grit, and the association between grit and health behaviors among at-risk Latino adolescents. Methods We analyzed baseline survey data collected in 2013–2014 from a sample of 1270 9th graders in low-income neighborhoods of Los Angeles. We examined factors associated with grit and whether grit is associated with substance use and delinquent behaviors, controlling for adolescent and parent sociodemographic factors. Results In a sample of mostly Latino adolescents (89.5%), compared to those with low grit, those with high grit had significantly lower odds of alcohol use in the last 30 days (odds ratio 0.30, P < .001), marijuana use (odds ratio 0.21, P < .05), and fighting (odds ratio 0.58, P < .05). Involvement in delinquent behavior was also lower (β = −0.71, P < .001). Factors associated with more grit included authoritative parenting style, parental employment, and high self-efficacy scores. Conclusions Grit may be an important candidate protective factor against substance use and other risk behaviors among Latino adolescents.
Although racial stigma in school is associated with adolescent risky health behaviors, there are no studies investigating how gender stigma relates to adolescent risky health behaviors among ...low-income, minority youth. We sought to determine whether gender stigma awareness is associated with adolescent risky health behaviors (delinquency, fighting, and substance use) and whether this association is mediated by school disengagement (low perceived teacher support, low school engagement, cutting classes, and breaking school rules) among low-income, minority students.
We analyzed cross-sectional survey data, collected from 2017 to 2019, from 412 high school students. Multi-level logistic regressions tested whether gender stigma awareness was associated with delinquency, fighting, and substance use, controlling for covariates, baseline behaviors, and clustering within schools. Mediation analyses tested whether school disengagement (low school engagement, perceived teacher support, cutting class, and breaking school rules) mediated these associations. Secondary analyses explored whether associations differed for male versus female, high-performing versus low-performing, and Latinx versus non-Latinx students.
In this predominantly Latinx (83%) sample, gender stigma awareness was associated with delinquency (AOR = 1.48, P< 0.001) and fighting (AOR = 1.15, P< 0.001). School engagement, perceived teacher support, breaking school rules, and cutting classes mediated 42.7% of the association between gender stigma awareness and delinquency and 65.42% of the association between gender stigma awareness and fighting. Gender stigma awareness was also associated with substance use for low-performing (AOR = 1.68, P = 0.003) and non-Latinx adolescents (AOR = 3.80, P = 0.03). School disengagement did not mediate the association between gender stigma awareness and substance use for non-Latinx students but mediated 50% of this association for low-performing students.
Gender stigma awareness is associated with adolescent risky health behaviors. A decreased sense of acceptance in the school community and increased school misbehavior may mediate these associations. School environments that value and accept all students may better support adolescent health.
Background
The stigma of HIV-infection may profoundly affect the lives of persons living with HIV/AIDS (PLHA). However few studies have examined the association of HIV stigma with multiple components ...of HIV treatment and care.
Objectives
To estimate the association between HIV stigma and: self-reported access to care, regular source of HIV care, and antiretroviral therapy adherence; and to test whether mental health mediates these associations.
Design
Cross-sectional study.
Participants
202 PLHA living in Los Angeles County in 2007.
Measurements
Participants completed an anonymous survey, assessing internalized HIV stigma (28-items, alpha = 0.93), self-reported access to medical care (six items, alpha = 0.75), regular source of HIV care, and antiretroviral therapy (ART) adherence.
Results
One-third of participants reported high levels of stigma; 77% reported poor access to care; 42.5% reported suboptimal ART adherence; and 10.5% reported no regular source of HIV care. In unadjusted analysis, those reporting a high level of stigma were more likely to report poor access to care (OR = 4.97, 95% CI 2.54–9.72), regular source of HIV care (OR = 2.48, 95% CI 1.00–6.19), and ART adherence (OR = 2.45, 95% CI 1.23–4.91). In adjusted analyses, stigma was significantly associated with poor access to care (OR = 4.42, 95% CI 1.88–10.37), but not regular source of HIV care or ART adherence. Mental health mediated the relationship between stigma and ART adherence, but not poor access to care or regular source of HIV care.
Conclusions
The association of stigma with self-reported access to care and adherence suggests that efforts to improve these components of HIV care will require a better understanding of the possible effects of stigma and it′s mediators.
To test whether providing information to parents about their child's academic performance and behavior in school will lead to lower rates of adolescent substance use.
We performed a randomized ...controlled trial in Los Angeles, California. We enrolled 318 seventh graders and their parents in 2014 and collected data through 2016. Half of the participants had parents with income less than $15 000, and 81% were Latino. During this intervention, Linking Information and Families Together, we sent parents weekly text messages, telephone calls, or e-mails about missed assignments, grades, and behavior. Parents reported their monitoring and parenting self-efficacy; students reported their use and intentions to use alcohol, marijuana, and other drugs.
By the end of eighth grade, lifetime use of alcohol or marijuana was 18.2% in the control group and 10.2% in the intervention group (
= .02). Parenting self-efficacy, parent-child relationship, and student's grades were similar between groups.
The intervention successfully reduced adolescent alcohol and marijuana initiation between grades 7 and 8. The intervention cost $15 per student per year but could be automated, reducing the marginal cost toward zero. The intervention holds promise as a scalable and innovative approach to reducing substance use.
ClinicalTrials.gov Identifier: NCT02129153.
PDF
