Ryan W. Walters

Relationship between Vitamin D, Parathyroid Hormone, and Bone Health

CONTEXT There is a controversy regarding the definition of vitamin D insufficiency as it relates to bone health. OBJECTIVE The objective of the study was to examine the evidence for a threshold value of serum 25-hydroxyvitamin D (25OHD) that defines vitamin D insufficiency as it relates to bone health. DESIGN AND PARTICIPANTS This was a cross-sectional analysis of baseline data in 488 elderly Caucasian women, mean age 71 yr, combined with a literature review of 70 studies on the relationship of serum PTH to serum 25OHD. SETTING The study was conducted in independent-living women in the midwest United States. MAIN OUTCOME MEASURE The relationship between serum 25OHD, serum PTH, and serum osteocalcin and 24-h urine N-telopeptides was evaluated. RESULTS Serum PTH was inversely correlated with serum 25OHD (r = -0.256, P < 0.0005), but no threshold as defined by suppression of serum PTH was found within the serum 25OHD range 6-60 ng/ml (15-150 nmol/liter). However, in contrast, there was a threshold for bone markers, serum osteocalcin and urine N-telopeptides, that increased only below a serum 25OHD of approximately 18 ng/ml (45 nmol/liter). Calcium absorption was not correlated with serum PTH and serum 25OHD, and no threshold was found. A literature review of 70 studies generally showed a threshold for serum PTH with increasing serum 25OHD, but there was no consistency in the threshold level of serum 25OHD that varied from 10 to 50 ng/ml (25-125 nmol/liter). CONCLUSIONS Vitamin D insufficiency should be defined as serum 25OHD less than 20 ng/ml (50 nmol/liter) as it relates to bone.

Educational Technology Use Among US Colleges and Schools of Pharmacy

Objective. To develop a searchable database of educational technologies used at schools and colleges of pharmacy. Methods. A cross-sectional survey design was used to determine what educational technologies were being used and to identify an individual at each institution who could serve as an information resource for peer-to-peer questions. Results. Eighty-nine survey instruments were returned for a response rate of 75.4%. The resulting data illustrated the almost ubiquitous presence of educational technology. The most frequently used technology was course management systems and the least frequently used technology was microblogging. Conclusions. Educational technology use is trending toward fee-based products for enterprise-level applications and free, open-source products for collaboration and presentation. Educational technology is allowing educators to restructure classroom time for something other than simple transmission of factual information and to adopt an evidence-based approach to instructional innovation and reform.

Evidence that Aerobic Fitness Is More Salient than Weight Status in Predicting Standardized Math and Reading Outcomes in Fourth- through Eighth-Grade Students

OBJECTIVE To determine whether aerobic fitness is more salient than weight status in predicting performance on standardized math and reading tests in fourth- to eighth-grade students. STUDY DESIGN A cross-sectional study of data abstracted from 11,743 students in 47 public schools. Aerobic fitness was defined by entering the healthy fitness zone of Fitnessgrams Progressive Aerobic Cardiovascular Endurance Run, which has been shown to correlate highly with maximum oxygen consumption. Mixed-effects logistic regression analyses were conducted to model the student-level effect of aerobic fitness status on passing the Nebraska State Accountability (NeSA) math and reading tests after adjusting for body mass index (BMI) percentile, free/reduced lunch status, sex, race, grade level, and school type. RESULTS After adjustment, aerobically fit students had greater odds of passing the NeSA math and reading tests compared with aerobically unfit students regardless of whether the students received free/reduced lunch; however, the effect of being aerobically fit on the standardized test scores was significantly greater for students not receiving free/reduced lunch. Weight status, as measured by BMI percentile, was not a significant predictor of passing the NeSA math or reading test after including free/reduced lunch status in the model. CONCLUSIONS Aerobic fitness was a significant predictor of academic performance; weight status was not. Although decreasing BMI for an overweight or obese child undoubtedly improves overall health, results indicated all students benefit academically from being aerobically fit regardless of weight or free/reduced lunch status. Therefore, to improve academic performance, school systems should focus on the aerobic fitness of every student.

Aggregated N-of-1 Randomized Controlled Trials: Modern Data Analytics Applied to a Clinically Valid Method of Intervention Effectiveness

OBJECTIVE Aggregated N-of-1 randomized controlled trials (RCTs) combined with multilevel modeling represent a methodological advancement that may help bridge science and practice in pediatric psychology. The purpose of this article is to offer a primer for pediatric psychologists interested in conducting aggregated N-of-1 RCTs. METHODS An overview of N-of-1 RCT methodology is provided and 2 simulated data sets are analyzed to demonstrate the clinical and research potential of the methodology. RESULTS The simulated data example demonstrates the utility of aggregated N-of-1 RCTs for understanding the clinical impact of an intervention for a given individual and the modeling of covariates to explain why an intervention worked for one patient and not another. CONCLUSIONS Aggregated N-of-1 RCTs hold potential for improving the science and practice of pediatric psychology.

The effect of a mechanical ventilation discontinuation protocol in patients with simple and difficult weaning: impact on clinical outcomes.

OBJECTIVE: We sought to determine whether the utilization of a respiratory therapist (RT) driven mechanical ventilation weaning protocol is associated with improvement in clinical outcomes in subjects with simple versus difficult weaning. METHODS: This was a retrospective analysis of prospectively collected data obtained during a quality improvement project. We collected data on 803 consecutive mechanically ventilated patients admitted to the ICU of an academic tertiary care hospital. We compared an RT-driven weaning protocol to a physician-driven weaning strategy. RESULTS: Of the 803 patients, 651 with simple weaning and 131 with difficult weaning were included in the analysis. In the subjects with simple weaning, 514 (79%) were weaned with the RT-driven protocol. Among the difficult weaning subjects, 101(77.1%) were liberated with the RT-driven protocol. A multivariate analysis, which included Acute Physiology and Chronic Health Evaluation II, body mass index, and type of primary ICU team under which the subjects were admitted, revealed a significant difference in ventilator-free days at 28-days, which supports the RT-driven protocol over the physician-driven strategy. Specifically, the RT-driven protocol increased ventilator-free days by 20.92% and 68.2% among subjects with simple and difficult weaning, respectively. A multivariate analysis of ICU mortality and extubation failure found no significant difference between the RT-driven protocol and the physician-driven strategy. CONCLUSIONS: The RT-driven weaning protocol increased ventilator-free days among subjects with simple and difficult weaning, with no significant differences in ICU mortality or extubation failure.

Impact of Pharmacist Intervention on Diabetes Patients in an Ambulatory Setting

Diabetes is the seventh-leading cause of death in the United States, according to the National Center for Health Statistics at the Centers for Disease Control and Prevention.1 More than 20 million people in the United States have diabetes, and of those > 60 years of age, one in five has the disease.1 Sixty-five percent of patients with diabetes die from heart disease or stroke. Thirty percent of those > 40 years of age have impaired sensation in their feet; 60% of all nontraumatic amputations are attributed to diabetes.1 Diabetes is also the leading cause of kidney failure, accounting for 44% of all new cases in 2002.1 To help prevent long-term complications and deaths related to diabetes, the American Diabetes Association (ADA) publishes an annual position statement titled Standards of Medical Care in Diabetes to provide up-to-date guidelines for the management of diabetes.2 The care of diabetes patients is multifaceted and often requires special attention to achieve optimum results. A1C testing is considered the gold standard measurement for diabetes control. Previous studies have measured A1C values in patients before and after seeing a pharmacist.3-7 The current study assessed A1C changes resulting from seeing a pharmacist and then compared them to changes that result from usual care to find out whether pharmacist care results in any additional benefit. This study investigated the clinical pharmacists impact on type 2 diabetes patients as measured by the change in A1C over a 2-year period in an outpatient clinic at a Veterans Administration institution. Diabetes care for the treatment group included the pharmacist, dietitian, and primary care provider (Team), with patients managed by the primary care provider and dietitian serving as controls (Control). For Team patients, a clinical pharmacist met with patients every 3 months or as needed …

Incidence of ventilator associated pneumonia in burn patients with inhalation injury treated with high frequency percussive ventilation versus volume control ventilation: A systematic review

BACKGROUND Pneumonia increases mortality in burn patients with inhalation injuries. We evaluated whether the use of High Frequency Percussive Ventilation (HFPV) in burn patients with inhalation injuries can decrease rates of Ventilator Associated Pneumonia (VAP) compared to Volume Control Ventilation (VCV). METHODS Data were gathered from PubMed, EMBASE, Web of Science, reference lists, and hand search. For unpublished data we searched ClinicalTrials.gov and RePORTER. We included observational and Randomized Controlled Trials (RCTs) that compared rates of VAP with the use of HFPV and VCV in adult burn patients with inhalation injury. Two reviewers independently extracted data from the retrieved studies and assessed them for eligibility, methodology, and quality. RESULTS 281 abstracts were reviewed, of which 4 studies (540 patients) were included. Two were observational and two were RCTs. All studies had moderate risk of bias. One study had low external validity while others had moderate external validity. The two observational studies found non-concordant results. One study found a 24% statistically significant reduction in the rates of VAP while the other found no difference. The two RCTs had small sample sizes. There was no significant difference in VAP rates between HFPV and VCV. The VCV arms of the four studies were heterogeneous. Only one study used low tidal volumes, whereas the rest used high tidal volumes in the VCV arm. CONCLUSION Evidence about decreased incidence of VAP in burn patients with inhalation injuries who are on HFPV compared to those on VCV is inconclusive. Although enhanced airway clearance by HFPV was thought to play a role in decreasing VAP in this population, high tidal volume in the VCV arms could be a confounding factor that should be eliminated in future studies before a firm conclusion can be reached. More RCTs comparing HFPV to low tidal volume VCV are needed.

Bidirectional Associations Between Psychological States and Physical Activity in Adolescents: A mHealth Pilot Study

Objective To understand the predictors and consequences of adolescent moderate-to-vigorous physical activity (MVPA) and sedentary behavior in nearly real-time. Methods Participants were 26 adolescents ( M age = 15.96, SD  = 1.56) who provided 80 self-reports of subjective states and continuous objective reports of MVPA and sedentary behavior over 20 days. Results Random effects were observed for all of the models with affect and feeling variables predicting MVPA. There was a negative fixed effect for within-person positive affect and sedentary behavior and the inverse association for negative affect. Within-person MVPA was a significant positive predictor of positive affect and energy. There was a random effect for within-person MVPA and fatigue. There was a significant random effect for within-person sedentary behavior predicting positive affect. Within-person sedentary behavior was a significant negative predictor of energy. Conclusions Findings highlight the importance of the intrapersonal nature of the associations among subjective states and physical activity.

Serum hyperchloremia as a risk factor for acute kidney injury in patients with ST-segment elevation myocardial infarction undergoing percutaneous coronary intervention

A high serum chloride concentration has been associated with the development of acute kidney injury in critically ill patients. However, the association between hyperchloremia and acute kidney injury (AKI) in patients admitted with ST-segment elevation myocardial infarction (STEMI) treated with percutaneous coronary intervention (PCI) is unknown. A retrospective analysis of consecutive patients admitted with the diagnosis of STEMI and treated with PCI was performed. Subjects were classified as having hyper- or normochloremia based upon their admission serum chloride level. Multivariable logistic regression analyses were employed for the primary and secondary outcomes. The primary analysis evaluated whether high serum chloride on admission was associated with the development of AKI after adjusting for age, diabetes mellitus, admission systolic blood pressure, contrast volume used during angiography, Killip class, and need for vasopressor therapy or intraaortic balloon pump. The secondary analyses evaluated whether high serum chloride was associated with sustained ventricular tachycardia or fibrillation. Of 291 patients (26.1% female, mean age of 59.9 ± 12.6 years, and mean body mass index of 29.3 ± 6.1 kg/m2), 25 (8.6%) developed AKI. High serum chloride on admission did not contribute significantly to the development of AKI (odds ratio, 95%; confidence interval, 0.90 to 1.24). In addition, serum chloride on admission was not significantly associated with sustained ventricular tachycardia or fibrillation after adjusting for demographic and clinical covariates. In conclusion, our study demonstrated no association between baseline serum hyperchloremia and an increased risk of AKI in patients admitted with STEMI treated with PCI.

Penetrating injuries to the duodenum: An analysis of 879 patients from the National Trauma Data Bank, 2010 to 2014

BACKGROUND Despite wide belief that the duodenal Organ Injury Scale has been validated, this has not been reported in the published literature. Based on clinical experience, we hypothesize that the American Association for Surgery of Trauma Organ Injury Scale (AAST-OIS) for duodenal injuries can independently predict mortality. Our objectives were threefold: (1) describe the national profile of penetrating duodenal injuries, (2) identify predictors of morbidity and mortality, and (3) validate the duodenum AAST-OIS as a statistically significant predictor of mortality. METHODS Using the Abbreviated Injury Scale 2005 and International Classification of Diseases—9th Rev.—Clinical Modification (ICD-9-CM) E-codes, we identified 879 penetrating duodenal trauma patients from the National Trauma Data Bank between 2010 and 2014. We controlled patient-level covariates of age, biological sex, systolic blood pressure (SBP), Glasgow Coma Scale (GCS) score, pulse, Injury Severity Score (ISS), and Organ Injury Scale (OIS) grade. We estimated multivariable generalized linear mixed models to account for the nesting of patients within trauma centers. RESULTS Our results indicated an overall mortality rate of 14.4%. Approximately 10% of patients died within 24 hours of admission, of whom 76% died in the first 6 hours. Patients averaged approximately five associated injuries, 45% of which involved the liver and colon. Statistically significant independent predictors of mortality were firearm mechanism, SBP, GCS, pulse, ISS, and AAST-OIS grade. Specifically, odds of death were decreased with 10 mm Hg higher admission SBP (13% decreased odds), one point higher GCS (14.4%), 10-beat lower pulse (8.2%), and 10-point lower ISS (51.0%). CONCLUSION This study is the first to report the national profile of penetrating duodenal injuries. Using the National Trauma Data Bank, we identified patterns of injury, predictors of outcome, and validated the AAST-OIS for duodenal injuries as a statistically significant predictor of morbidity and mortality. LEVEL OF EVIDENCE Epidemiologic/Prognostic, level IV.