Colleen Kalynych

A Mediterranean-style low-glycemic-load diet improves variables of metabolic syndrome in women, and addition of a phytochemical-rich medical food enhances benefits on lipoprotein metabolism

BACKGROUND The high prevalence of metabolic syndrome (MetS) has highlighted the need for effective dietary interventions to combat this growing problem. OBJECTIVE To assess the impact of a Mediterranean-style low-glycemic-load diet (control arm, n = 44) or the same diet plus a medical food containing phytosterols, soy protein, and extracts from hops and acacia (intervention arm, n = 45) on cardiometabolic risk variables in women with MetS. METHODS In this 12-week, 2-arm randomized trial, baseline, week 8 and 12, fasting blood samples were drawn to measure plasma lipids, apolipoproteins, and homocysteine. Dietary records were also collected and analyzed. RESULTS There were decreases in fat and sugar intake (P < .001 for both) and increases in docosahexaenoic acid and eicosapentaenoic acid intake (P < .001 for both) over time, consistent with the prescribed diet. Regarding MetS variables, there were decreases in waist circumference, systolic and diastolic blood pressure, and plasma triglycerides in all subjects (P < .001 for all) with no differences between arms. Plasma low-density lipoprotein cholesterol, non-high-density lipoprotein cholesterol, apolipoprotein (apo) B, and apo B/apo A1 were reduced over time but to a greater extent in the intervention arm (P < .05 for all), indicating the medical food had a greater effect in altering lipoprotein metabolism. Further, medical food intake was associated with reduced plasma homocysteine (P < .01) compared to the control arm. CONCLUSION A Mediterranean-style low-glycemic-load diet effectively reduces the variables of MetS. Addition of the medical food results in a less atherogenic lipoprotein profile and lower plasma homocysteine.

Waist circumference is positively correlated with markers of inflammation and negatively with adiponectin in women with metabolic syndrome

The purpose of this study was to correlate biomarkers of metabolic syndrome (MetS), with markers of inflammation and macronutrient intake in 89 women (25-72 years) with MetS. We hypothesized that waist circumference (WC) would have the stronger correlations with inflammatory parameters and would correlate with carbohydrate intake. Values for WC (108.7 ± 11.1 cm) and plasma triglycerides (202.7 ± 52.1 mg/dL) were elevated, whereas plasma glucose levels varied from 66 to 179 mg/dL, with 42% of women having insulin resistance. Plasma levels of interleukin 6 (0.2-15.9 mg/L), tumor necrosis factor α (1.47-12.3 mg/L), and high-sensitivity C-reactive protein (0.06-3.08 mg/dL) varied widely, with most women being above values considered normal. Subjects had high intake of total sugar (92.3 ± 56.4 g/d), high glycemic index (59.8 ± 6.5), and glycemic load (127.2 ± 56.1), whereas dietary fiber (17.1 ± 9.1 g/d) was below recommended intake. Waist circumference was positively correlated with insulin (r = 0.275, P < .01) and with the inflammatory markers interleukin 6 (r = 0.307, P < .01) and tumor necrosis factor α (r = 0.228, P < .05) and negatively correlated with plasma adiponectin (r = -0.309, P < .0001). In addition, WC was positively correlated with total carbohydrate, added sugar, and glycemic load (P < .05) but not with fat or protein. These results are consistent with central obesity being a key marker of the inflammatory state, and they also suggest that carbohydrates, particularly those that are digested rapidly, contribute to increased risk of central obesity and development of MetS.

Knowledge assessment of sports-related concussion among parents of children aged 5 years to 15 years enrolled in recreational tackle football.

BACKGROUND Sports-related concussion among professional, collegiate, and, more recently, high school athletes has received much attention from the media and medical community. To our knowledge, there is a paucity of research regarding parental knowledge of sports-related concussion. The aim of this study was to evaluate parental knowledge of concussion in young children who participated in recreational tackle football. METHODS Parents of children aged 5 years to 15 years attending recreational tackle football games were asked to complete an anonymous questionnaire based on the Centers for Disease Control and Prevention’s Heads Up: Concussion in Youth Sports Quiz. The parents were asked about their level of agreement regarding statements that represent definition, symptoms, and treatment of concussion. RESULTS A total of 310 of 369 parents (84% response rate) voluntarily completed the questionnaire, with 94% believing that their child had never had a concussion. However, only 13% (n = 41) could correctly identify all seven statements. Most did not identify that a concussion is considered a mild traumatic brain injury and can be achieved from something other than a direct blow to the head. Race, sex, and zip code had no significant association with correctly answering statements. Education (r = 0.24, p < 0.0001) and number of years the child played (r = 0.11, p = 0.049) had a small association. Fifty-three percent and 58% of the parents reported that someone had discussed the definition and the symptoms of concussion with them, respectively, with only about half reporting that information came from their health care provider. No parent was able to classify all symptoms listed as correctly related or not related to concussion. However, identification of correct concussion statements correlated with identification of correct symptoms (r = 0.25, p < 0.001). CONCLUSION While most parents of young athletes demonstrated some knowledge regarding concussion, important misconceptions remain regarding the definition, symptoms, and treatment of concussion. This study highlights the need for health care providers to increase concussion educational efforts. LEVEL OF EVIDENCE Epidemiologic study, level II.

Persistent organ dysfunction after severe sepsis: A systematic review☆

OBJECTIVE Sepsis is a prevalent disease with high mortality. Survivors of sepsis often suffer significant resultant morbidity, including organ dysfunction. However, little is known about persistent or long-term organ dysfunction in this patient population. Our objective was to systematically review original research studies evaluating organ-specific outcomes at 28 days or greater in patients surviving severe sepsis. METHODS We performed a systematic review of studies reporting organ-specific outcomes at 28 days or greater in survivors of severe sepsis. RESULTS We identified 1,173 articles and five met our inclusion criteria. No study reported on organ dysfunction at greater than 30 days. Two studies contributed the majority of patients and had consistent rates of 1 month organ dysfunction for adult respiratory distress syndrome (ARDS) (8%-9%), renal (7%-8%), hepatic (3%-7%), and central nervous system (2%-5%). Another study reported higher rates of dysfunction for pulmonary (non-ARDS and ARDS), hepatic and renal but similar rates for central nervous system and disseminated intravascular coagulation when compared to the first two studies. The most recent study had the highest rates of dysfunction (>47%) across all organ systems. For organ failure resolution the rates were highly variable. CONCLUSIONS Our review found variable rates of organ dysfunction at 1 month after severe sepsis. Future studies should attempt to characterize organ dysfunction at greater than 1 month after an acute severe sepsis episode to determine the true prevalence long-term organ dysfunction and treatments for prevention. Additionally, standardized objective measures of organ dysfunction are needed so that future studies can be directly compared.

Low HDL cholesterol is associated with increased atherogenic lipoproteins and insulin resistance in women classified with metabolic syndrome

Both metabolic syndrome (MetS) and elevated LDL cholesterol (LDL-C) increase the risk for cardiovascular disease (CVD). We hypothesized that low HDL cholesterol (HDL-C) would further increase CVD risk in women having both conditions. To assess this, we recruited 89 women with MetS (25-72 y) and LDL-C ≥ 2.6 mmol/L. To determine whether plasma HDL-C concentrations were associated with dietary components, circulating atherogenic particles, and other risk factors for CVD, we divided the subjects into two groups: high HDL-C (H-HDL) (≥ 1.3 mmol/L, n = 32) and low HDL-C (L-HDL) (< 1.3 mmol/L, n = 57). Plasma lipids, insulin, adiponectin, apolipoproteins, oxidized LDL, Lipoprotein(a), and lipoprotein size and subfractions were measured, and 3-d dietary records were used to assess macronutrient intake. Women with L-HDL had higher sugar intake and glycemic load (P < 0.05), higher plasma insulin (P < 0.01), lower adiponectin (P < 0.05), and higher numbers of atherogenic lipoproteins such as large VLDL (P < 0.01) and small LDL (P < 0.001) than the H-HDL group. Women with L-HDL also had larger VLDL and both smaller LDL and HDL particle diameters (P < 0.001). HDL-C was positively correlated with LDL size (r = 0.691, P < 0.0001) and HDL size (r = 0.606, P < 0.001), and inversely correlated with VLDL size (r = -0.327, P < 0.01). We concluded that L-HDL could be used as a marker for increased numbers of circulating atherogenic lipoproteins as well as increased insulin resistance in women who are already at risk for CVD.

Color coded medication safety system reduces community pediatric emergency nursing medication errors.

Objectives: To compare the performance of current systems in place for preparation and administration of pediatric medications in community emergency departments to the color-coded medication safety (CCMS) system among nurses. Methods: Community ED nurses participated in simulated pediatric emergency scenarios using traditional dosing references then the CCMS system. We measured preintervention/postintervention: (1) time to task completion from physician order to medication administration; (2) accuracy of conversion to milliliters, dilution, and time for medication administration; and (3) recognition of 10-fold physician errors. Results: A total of 320 medication and infusion orders were given to 16 nurses. The median time to task completion preintervention was 109 seconds (interquartile range, 44-626). Time to task completion was reduced to a median of 28 seconds (interquartile range, 14-43; P < 0.001) with the CCMS system. Significant error reductions were noted when nurses used the CCMS system: 25.6% of medications were converted incorrectly compared with 2.5% with the system, a 23% improvement (95% confidence interval [CI], 13-33; P < 0.001), 35.6% were diluted incorrectly compared with 0.63%, a 35% improvement (95% CI, 26-44; P < 0.001), and 54.7% were administered incorrectly compared with 3.9%, a 51% improvement (95% CI, 39-61; P < 0.001). Only 20% of 10-fold physician order errors were recognized preintervention but 93% were recognized using the CCMS system, a 73% improvement. Conclusions: The CCMS system reduces pediatric medication delay and improves nursing accuracy. This is important in the community ED setting where many children receive emergency care and where providers may lack familiarity with pediatric medication dosing.

Proactive rounding by the rapid response team reduces inpatient cardiac arrests

OBJECTIVE Rapid response teams (RRTs) are frequently employed to respond to deteriorating inpatients. Proactive rounding (PR) consists of the RRT nurse rounding through the inpatient wards identifying high risk patients and intervening preemptively. At our institution, PR began in July of 2007. Our objective was to determine the effect of PR by the RRT at our institution on non-ICU cardiac arrests, code deaths, RRT interventions, and transfers to a higher level of care. Also, to report ICU transfer survival and survival to discharge rates after the start of PR. DESIGN Retrospective review of a prospectively collected database. SETTING A tertiary, academic, level 1 trauma center with 696 beds and a rapid response system. PATIENTS 1253 Non-ICU cardiac arrests from 2005 through June of 2012. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS The total study period included 223,267 inpatient admissions (70,129 pre-PR and 153,138 post-PR) and 1,250,814 patient days (391,088 pre-PR and 859,726 post-PR). The quarterly code rate before PR was 66 and the code rate after the institution of PR was 30 (difference=36.8, 95% CI 25.6-48.0, p<.001). Quarterly code deaths decreased from 29 to 7 (difference=21.95, 95% CI 16.3-27.6, p<.001). This decrease in floor codes and code deaths was still present after adjusting for inpatient admission and inpatient days. Average quarterly RRT interventions increased from 141 in the pre-PR period to 690 in the post-PR period (difference=549, 95% CI 360-738, p<.001). Average quarterly transfers to HLC went up from 38 pre-PR to 164 post-PR (difference=126, 95% CI 79-172, p<.001). CONCLUSIONS The institution of proactive rounding at a tertiary care, academic, level 1 trauma center results in reduced floor codes and code deaths as well as increased RRT interventions and transfers to a higher level of care.

The long-term burden of severe sepsis and septic shock: Sepsis recidivism and organ dysfunction.

BACKGROUND Severe sepsis and septic shock mortality has improved; however, rates of persistent (28–90 days) and long-term (>90 day) organ dysfunction in sepsis survivors are unknown. METHODS Secondary analysis of a prospective cohort of adult emergency department patients with severe sepsis. RESULTS Of 110 sepsis admissions, we obtained follow-up on 51 of 78 survivors of whom 41% (21 of 51) had persistent organ dysfunction: pulmonary, 18% (9 of 51); renal, 22% (11 of 51); coagulopathy, 10% (5 of 51); cardiovascular, 6% (3 of 51); hepatic, 2% (1 of 51); and neurologic, 3% (3 of 51). We obtained follow-up on 40 of 73 survivors at more than 90 days of whom 38% (15 of 40) had long-term organ dysfunction: pulmonary, 13% (5 of 40); renal, 18% (7 of 40); coagulopathy, 3% (1 of 40); cardiovascular, 5% (2 of 40); hepatic, 0%; and neurologic, 5% (2 of 40). Readmission rate within 90 days was 32% (25 of 78), and recurrent sepsis was the cause of readmission in 52% (13 of 25). Baseline SOFA scores from the index sepsis admission were compared using Wilcoxon rank-sum test and were significantly different in participants with organ dysfunction versus those without organ dysfunction at less than 90 days (z, −2.51; p = 0.01). CONCLUSION Readmission with recurrent sepsis and organ dysfunction occurs frequently in sepsis survivors. Baseline SOFA score may be predictive of sepsis recidivism and persistent or recurrent organ dysfunction. LEVEL OF EVIDENCE Prognostic/epidemiologic study, level IV.

A 6-year retrospective review of pediatric firearm injuries: do patients < 14 years of age differ from those 15-18 years of age?

BACKGROUND Pediatric firearm injuries are an increasing source of morbidity. Firearm injuries in adolescents are common but not well studied in younger children. The aims were to describe the epidemiology of firearm injuries in patients 0 year to 18 years old, with a case study of patients 14 years or younger for determining shooting characteristics and epidemiologic trends. METHODS Part 1 obtained data from hospital trauma registry. Inclusion criteria were patients 0 year to 18 years of age presenting from 2005 to 2010 with firearm injury and registry inclusion. Demographic and injury data were extracted. Part 2 included a retrospective review of patients 14 years or younger including hospital and emergency medical services records. Data from the group 0 year to 14 years included shooting and treatment details. Categorical variables were described using counts and percentages. Differences between the groups were assessed using odds ratios (ORs), along with 95%confidence intervals (CIs), extracted from logistic regression models. RESULTS Registry query resulted in 456 patients (0–18 years), including 78 patients who are 14 years or younger. In the group of 0 to 18 years, 86% were male; 83% were black in the group of 15 to 18 years and 64% in the group 0 to 14 years. Overall death rate was 7%. Patients in the group of 15 years to 18 years were twice more likely (23% vs. 11%) to arrive via car or walk-in compared with the patients in the group of 0 year to 14 years (OR, 2.32;95% CI, 1.07–5.03). Patients in the group of 0 year to 14 years were almost four times more likely to be shot at home compared with those who are 15 years to 18 years (OR, 3.76; 95% CI, 2.29–6.19). Patients in the group of 5 years to 9 years were six times more likely to have multiple injury sites compared with those who are 10 years to 14 years (OR, 6.26; 95% CI, 1.26–31.09). Only 13% had documented child protective services notification. CONCLUSION Results from this study suggest that firearm injuries differ in younger patients compared with adolescents. The younger subset was more likely to be shot at home versus public settings. Hospital and emergency medical services records lacked important shooting details often found in crime scene reports, which are necessary for the development of effective crime and prevention strategies. LEVEL OF EVIDENCE Epidemiologic study, level III.

The relationship of intravenous fluid chloride content to kidney function in patients with severe sepsis or septic shock

BACKGROUND Previous studies suggest a relationship between chloride-rich intravenous fluids and acute kidney injury in critically ill patients. OBJECTIVES The aim of this study was to evaluate the relationship of intravenous fluid chloride content to kidney function in patients with severe sepsis or septic shock. METHODS A retrospective chart review was performed to determine (1) quantity and type of bolus intravenous fluids, (2) serum creatinine (Cr) at presentation and upon discharge, and (3) need for emergent hemodialysis (HD) or renal replacement therapy (RRT). Linear regression was used for continuous outcomes, and logistic regression was used for binary outcomes and results were controlled for initial Cr. The primary outcome was change in Cr from admission to discharge. Secondary outcomes were need for HD/RRT, length of stay (LOS), mortality, and organ dysfunction. RESULTS There were 95 patients included in the final analysis; 48% (46) of patients presented with acute kidney injury, 8% (8) required first-time HD or RRT, 61% (58) were culture positive, 55% (52) were in shock, and overall mortality was 20% (19). There was no significant relationship between quantity of chloride administered in the first 24 hours with change in Cr (β = -0.0001, t = -0.86, R(2) = 0.92, P = .39), need for HD or RRT (odds ratio [OR] = 0.999; 95% confidence interval [CI], 0.999-1.000; P = .77), LOS >14 days (OR = 1.000; 95% CI, 0.999-1.000; P = .68), mortality (OR = 0.999; 95% CI, 0.999-1.000; P = .88), or any type of organ dysfunction. CONCLUSION Chloride administered in the first 24 hours did not influence kidney function in this cohort with severe sepsis or septic shock.