Racial and Ethnic Differences Among Active-Duty Service Members in Use of Mental Health Care and Perceived Mental Health Stigma: Results From the 2018 Health Related Behaviors Survey

INTRODUCTION

The prevalence of mental health disorders is rising among US service members; however, research is limited on their use of mental health care. The objective of our study was to determine whether racial and ethnic disparities exist in the use of mental health care and perceived mental health stigma among active-duty service members.

METHODS

We obtained data from a sample of 17,166 active-duty service members who participated in the 2018 Department of Defense Health Related Behavior Survey (HRBS). Racial and ethnic groups included Black, Hispanic, White, and other. Yes-no questions about use of mental health care and perceived mental health stigma were our outcome variables. We used multiple logistic regression to assess racial and ethnic differences in mental health care use and perceived mental health stigma by service members. Significance was set at P <.05.

RESULTS

In 2018, approximately 25.5% of service members self-reported using mental health services, and 34.2% self-reported perceived mental health stigma. Hispanic service members (AOR = 0.78) and service members in the "other" racial and ethnic group (AOR = 0.81) were less likely than their White counterparts to have used mental health care. Black (AOR = 0.68) and Hispanic (AOR = 0.86) service members were less likely than their White counterparts to self-report perceived mental health stigma.

CONCLUSION

The 2018 HRBS showed racial and ethnic differences in mental health care use and perceived stigma among US active-duty service members. Perceived stigma was a barrier to use of mental health care among service members with a mental health condition. Culture-sensitive programs customized for different racial and ethnic groups are needed to promote mental health care and reduce perceptions of stigma associated with its use.

Longitudinal Patterns of Beverage Intake in Treatment-Seeking Children with Obesity in Eastern NC Using the Validated BEVQ-15

Sugar-sweetened beverage (SSB) consumption remains a major target for interventions to treat severe obesity in children. Understanding how total energy consumption is divided among different types of beverages remains unclear. This study retrospectively examined how the consumption of beverage calories (kcal) from 100% fruit juice and SSBs, and body mass index, assessed as a percent of the 95th sex- and age-specific percentile (%of 95BMI), changed during the treatment of children with obesity aged 2-18 years. Treatment was provided by an integrative multi-disciplinary team, comprising a physician, a dietician/ nutritionist and a behavioralist employing motivational interviewing and a small change approach to promote improved sustainable health habits and induce a net negative energy balance. The sample included 155 patients, with 341 visits. The median age was 11 years, 60% were girls, and there was a median follow-up of 3.1 months. At baseline, the median %of 95BMI was 135 and the median kcal/day intake was 436 from juice and 263 from SSB. For each additional 100 kcal consumed/day from SSB and juice, the %of 95BMI increased by 1.4 percentage points. In the follow-up, each additional month was associated with 7 fewer kcal/day from SSB and juice combined, with a 0.5 percentage point increase in %of 95BMI. Children in this treatment program consumed fewer calories from SSB over time, although the %of 95BMI did not decrease. SSBs other than soda accounted for the majority of beverage kcal intake, therefore potentially providing a targeted direction for interventions.

Racial/ethnic disparities in preventive dental services use and dental caries among children

OBJECTIVE

To assess disparities in preventive dental service use in four major racial/ethnic groups and assess whether racial/ethnic and income-related disparities among children were reduced from 2016 to 2020.

METHODS

Data were from the 2016 and 2020 National Survey of Children's Health (NSCH). The outcomes of interest were having dental sealants, fluoride treatment, and dental caries in the past 12 months. Racial/ethnic groups included non-Hispanic (NH) whites, blacks, Hispanics, Asians, and others. Family income level was categorized as below or above the 200% federal poverty level (low-income vs. high-income). Children ages 2-17 were included (N = 161,539). All data were self-reported by parents/guardians. We estimated the trends of racial/ethnic disparities in having fluoride treatment, dental sealants, and dental caries from 2016 to 2020 and tested two 2-way interactions (i.e., year by race/ethnicity, year by income) and one 3-way interaction (year by income by race/ethnicity) to assess the change in disparities from 2016 to 2020.

RESULTS

Overall, no significant trends in receipt of fluoride treatment, dental sealants, or having dental caries were found from 2016 to 2020 among the racial/ethnic groups, except for a decreasing trend in dental sealants for Asian American children (p = 0.03). Overall, NH white children were more likely to have received preventive dental services than children from minority groups (all p < 0.05); Asian American children (AOR = 1.31) were more likely to have dental caries than NH white children.

CONCLUSION

Disparities in receipt of evidence-based preventive services by children persisted. Continuous efforts are needed to promote the use of preventive dental services among children of minority populations.

Ethnicity and trends in pediatric specialty care clinic attendance at an academic medical center in the rural southeastern US

Following the 2016 US Presidential election, immigration enforcement became more aggressive, with variation by state and region depending on local policies and sentiment. Increases in enforcement created an environment of risk for decreased use of health care services among especially among Latino families. of Hispanic ethnicity and/or from Latin American origin (as a group subsequently referred to as Latino). For Latino children with chronic health conditions, avoidance of routine health care can result in significant negative health consequences such as disease progression, avoidable use of acute health care services, and overall increased costs of care. To investigate for changes in visit attendance during the periods before and since increased immigration enforcement, we extracted data on children followed by subspecialty clinics of one healthcare system in the US state of North Carolina during 2015-2019. For each patient, we calculated the proportion of cancelled visits and no-show visits out of all scheduled visits during the 2016-2019 follow-up period. We compared patient characteristics (at the 2015 baseline) according to whether they cancelled or did not show to any visits in subsequent years by clinic and patient factors, including ethnicity. Data were analyzed using multinomial logistic regression of attendance at each visit, including an interaction between visit year and patient ethnicity. Among 852 children 1 to 17 years of age (111 of Latino ethnicity), visit no-show was more common among Latino patients, compared to non-Latino White patients; while visit cancellation was more common among non-Latino White patients, compared to Latino patients. There was no significant interaction between ethnicity and trends in visit no-show or cancellation. Although differences in pediatric specialty clinic visit attendance by patient ethnicity were seen at study baseline, changing immigration policy and negative rhetoric did not appear to impact use of pediatric subspecialty care.

Determining Trends and Factors Associated with Self-Reported Physical Activity among Adolescents in Rural North Carolina

It is important to better understand factors associated with physical activity (PA) levels in adolescents in rural areas. Cross-sectional data were used to obtain self-reported PA levels among adolescents in a school-based intervention in fall 2018. Demographic data, environmental variables, and cardiovascular fitness (PACER score) were also measured. Analyses included a two-sample t-test, ANOVA, a Chi-square test_, and a linear regression model. Participants included 3799 7th graders. Male (p < 0.0001), white (p < 0.0001), and healthy weight (p < 0.0001) participants reported more days of PA. The correlation between school physical education (PE) and PACER was modest (r = 0.27, p < 0.0001). Multiple linear regression model showed significant effects of school PE (p = 0.0011), gender (p < 0.0001), race (p < 0.0001), and weight category (p < 0.0001) on self-reported PA. The percentage of students reporting 60 min of PA for 5 (p < 0.0001) or 7 (p = 0.0307) days per week tended to be higher with increased days per week of school PE. Policy changes that increase PA and PE in middle schools may present opportunities to improve PA levels in adolescents, with emphasis on being inclusive and mindful of minority and female youth.

Adaptation of a Modified Diet Quality Index to Quantify Healthfulness of Food-Related Toy Sets

The objective of this cross-sectional study was to examine the construct validity of an adapted modified Diet Quality Index (aDQI) as a measure of the healthfulness of food-related toy sets for young children (3-8 years). A standardized online search was used to identify toy sets (n = 50) from 10 retailers. An aDQI score (aDQI score, range 0-50) was determined for each toy set, mean (standard deviation) = 28.7 (6.1). Regression analyses demonstrated a positive association between aDQI score and percentage of dairy, refined grains, protein, vegetables, and fruit and inverse association with percentage of desserts, sugar-sweetened beverages, and total number of servings. Sets contained more protein and fewer fruits than recommended. The aDQI score demonstrates construct validity to objectively assess the healthfulness of food-related toy sets. There is opportunity for toy manufacturers to make changes to improve the healthfulness in toy sets for young children, and future research can explore the impact of food-related toy sets on nutrition behaviors.

Preparing Faculty to Incorporate Health Systems Science into the Clinical Learning Environment: Factors Associated with Sustained Outcomes

This study assesses participants' perceptions of long-term impacts of the Teachers of Quality Academy, a medical school faculty development program designed to prepare faculty to both practice and teach health system science. A previously published 1-year evaluation of the first cohort of 27 participants showed improved perceived skills, with positive career and health system impacts. In this 5-year evaluation, a mixed-methods design included a questionnaire followed by semistructured interviews to assess perceived long-term impacts on participants. Quantitative and qualitative analyses were completed. Questionnaire response rate was 88% (N = 22), and 14 interviews were analyzed. Results demonstrated that participants had incorporated quality improvement concepts into their clinical work and teaching, better understood interprofessionalism, and observed continued improvements in care delivery. They felt the longitudinal training, delivered in a shared setting, created a learning community with lasting positive effects in institutional culture, supported long-term professional development, and had broader institutional impact. Advancements in clinical care, medical education, and professional and academic advancements were noted.

Impact of Body Mass Index, Socioeconomic Status, and Bedtime Technology Use on Sleep Duration in Adolescents

Factors related to adolescents and sleep are understudied. We evaluate the relationship between bedtime technology use (TU), TV in bedroom, weight, and socioeconomic status in seventh graders (N = 3956) enrolled in a school-based wellness intervention. Sleep quantity was dichotomized to insufficient (<8 hours) or sufficient (≥8 hours); high TU before sleep was defined by use "a few nights each week" or "every, or almost every night." Insufficient sleep (38.7%), having TV in bedroom (72.9%), and high TU (83.1%) were commonly reported. The likelihood of sufficient sleep was lower for those with high TU (odds ratio [OR] = 0.529 [0.463-0.605]), obese students (OR = 0.815 [0.700-0.949]), and those with a TV in the bedroom (OR = 0.817 [0.703-0.950]). Also, attending a school with higher percent low socioeconomic status students was also associated with insufficient sleep (P = .026). Interventions to reduce TU may be important for improving sleep quantity, especially for some vulnerable populations.

Health Care in a Changing North Carolina Climate

North Carolina's health care systems face dramatic risks from climate change that are here now and will last for decades, including disease outcomes and increased health risks that will disproportionately affect disadvantaged populations. At the local level, health care practitioners have to become advocates for climate mitigation; longer-term responses must involve society at all levels.

Attachment, Parenting, and Obesogenic Behavior: A Dyadic Perspective

Pediatric obesity is a growing health concern afflicting the United States. The treatment for pediatric obesity, as a health epidemic, costs billions of dollars to our nation, leaving providers and researchers searching for effective and sustainable ways to better manage the biological, psychological, and social health of individuals and families. While many assessments and interventions continue to emerge, researchers have predominately focused on intra-individual concerns among white non-Hispanic populations. This quantitative study was grounded in a relational theory (attachment theory), with a dyadic and primarily Hispanic sample. Evidence from our study supported that child attachment predicted child obesogenic behavior and that this relationship was mediated by child self-regulation. Children with insecure attachments had more obesogenic behaviors and lower self-regulation of eating than those with secure attachments. Family therapists should be on the frontlines of relational research and clinical interventions that interface with biopsychosocial health across diverse cultures and families.

Tapping Out: Influence of Organoleptic and Perceived Health Risks on Bottled Versus Municipal Tap Water Consumption Among Obese, Low Socioeconomic Status Pediatric Patients

A variety of endocrine disrupting chemicals (EDCs), including some known to be obesogenic, can be found in household wastewater. Many are only partially treated by wastewater treatment and drinking water purification systems and can enter municipal drinking water supplies. We evaluated drinking water consumption habits in a cohort of obese pediatric patients to determine the percentage that might avoid exposure to EDCs from drinking municipal tap water. Obese (BMI ≥ 95^th percentile) children presenting to an obesity clinic serving a largely poor and rural population were studied. Self-reported race/ethnicity, insurance status and details concerning type and volume of water consumed were obtained from their medical records. Most homes were supplied with municipal, rather than private well water (90.6% vs. 9.4%, respectively). A majority (76.4%) of patients with municipal water as their water supply only drank bottled water. "Taste" and "Health Concerns" were the most commonly endorsed reasons for eschewing tap water. Bottled water consumption among low socioeconomic status patients may reduce their risk for exposure to EDCs in municipal tap water. Further studies are needed to confirm the generalizability of this observation.

Use of the Veggie Meter® as a tool to objectively approximate fruit and vegetable intake among youth for evaluation of preschool and school-based interventions

BACKGROUND

Reflection spectroscopy is an emerging, non-invasive objective measure used to approximate fruit and vegetable intake. The present study aimed to use a reflection spectroscopy device (the Veggie Meter®, Longevity Link Corporation, Salt Lake City, UT, USA) to assess skin carotenoid status in preschool, middle- and high-school students and to examine associations between skin carotenoids and self-reported dietary intake.

METHODS

In Autumn 2018, we used the Veggie Meter® to assess skin carotenoids and age-appropriate validated dietary assessment measures to approximate fruit and vegetable (FV) intake. Preschool participants completed a previously validated pictorial liking tool using an iPad (Apple Inc., Cupertino, CA, USA). Middle-school participants completed selected questions from the validated School Physical Activity and Nutrition (SPAN) (Michael & Susan Dell Center for Healthy Living, University of Texas, Austin, TX, USA) questionnaire regarding frequency of their FV and beverage intake on the previous day, with additional questions about physical activity. High-school participants' FV intake was assessed using the Fruit and Vegetable Screener (National Cancer Institute, Bethesda, MD, USA). Spearman correlation coefficients were used to determine bivariate associations between measures of dietary intake and Veggie Meter®-assessed skin carotenoid levels.

RESULTS

Mean (SD) Veggie Meter® readings were 266 (82.9), 219 (68.1) and 216 (67.2) among preschool, middle- and high-school students. There was an inverse association between soda intake and Veggie Meter® readings (r = -0.22, P = 0.03) among middle-school students; and a positive association between daily fruit intake and Veggie Meter® readings (r = 0.25, P = 0.06) among high-school students.

CONCLUSIONS

The Veggie Meter® comprises a promising evaluation tool for preschool and school-based nutrition interventions.

Providers' involvement of blended families in pediatric weight management programs

INTRODUCTION

Family based interventions are the standard for pediatric weight management programs (PWMPs), yet the details of how to involve additional family members, when youth are part of blended families (i.e., step families) or reside in multiple households is not well understood. The objective of this study is to describe how providers involve blended families and multiple households in PWMPs.

METHOD

A cross-sectional exploratory survey was conducted of providers at PWMPs in the United States and Canada. The survey questions included had both multiple choice and open-ended responses. Univariate analyses were conducted.

RESULTS

71 providers participated, representing 47 centers/clinics. The majority (96%) reported assessing multiple households, most often during the medical history. Providers reported including the primary caretakers at all known residences (59%), but not immediate family members beyond the primary caretakers. Providers reported adapting dietary (88%) and physical activity (77%) recommendations to accommodate multiple households. The most frequent adaptations included the goals at each family/household, adjustments on a per family basis or based on family resources, and making materials available to all family members. The most frequent challenges in extending treatment plans to multiple households included one caretaker/household not willing to participate or being present at visits, and inconsistency between households. Despite providers reporting that they assess multiple households, they did not have a formal interview template or form to use in assessments (27%).

DISCUSSION

Providers recognize the challenges and complexity that blended families present with in obesity treatment. Further research is need to increase provider assessment and involvement of blended families and the extension of goals and treatment plans to multiple homes. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

Examining the Association Between Screen Time, Beverage and Snack Consumption, and Weight Status Among Eastern North Carolina Youth

BACKGROUND With the rise in technology use for the adolescent population, screen time may be related to unhealthy eating habits and contribute to adolescent obesity. Since 2007, an adolescent wellness program, Motivating Adolescents to Choose Health (MATCH), has been implemented in select North Carolina middle schools.METHODS Using MATCH study data from fall 2015 in 26 North Carolina middle schools, we examined the cross-sectional associations between screen time, unhealthy beverage and snack consumption, and BMI z-score with linear regression models controlling for physical activity, school, sex, weight category, and race.RESULTS Of the 2,763 youth surveyed, half were female, 48% were white, 33% were black, and 19% were other racial groups; 2% were underweight, 51% were healthy weight, 21% were overweight, and 26% were obese. Mean BMI percentile was the 72nd percentile and mean BMI z-score was 0.81. The average of self-reported behaviors included: 1,312 hours of screen time per year, sugary beverages consumed 2,073 times per year, and unhealthy snacks consumed 3,485 times per year. There were positive associations between screen time per year and both sugary beverage (B = 0.4699; 95% Confidence Interval [CI], 0.3689-0.5709; P < .001), and unhealthy snack consumption per year (B = 1.0085; 95% CI, 0.8413-1.1757; P < .001), after controlling for significant covariates. This suggests that an extra hour of screen time a day is associated with approximately 172 extra servings of sugary beverages per year (3.3 extra servings per week, or 0.5 extra servings per day) and 368 extra servings of unhealthy snacks per year (7.1 extra servings per week, or 1 extra per day). No association was found with BMI z-score (B = -0.00001; 95% CI, -0.00007-0.00005; P = .697).LIMITATIONS The baseline survey questions did not differentiate between types of screen time, and self-reported data may have impacted results.CONCLUSION In North Carolina adolescents, increased screen time is associated with increases in both unhealthy beverage and snack consumption. Future research is needed to further elucidate how these factors and others impact BMI. MATCH may increase effectiveness by including program components that address the relationship between screen time and unhealthy dietary consumption.

Developing Tomorrow's Leaders: A Medical Student Distinction Track in Health System Transformation and Leadership

PROBLEM

Calls for medical education reform focus on preparing physicians to meet the challenges of today's complex health care system. Despite implementing curricula focused on health systems science (HSS), including quality improvement (QI), patient safety, team-based care, and population health, a significant gap remains in training students to meet the system's evolving needs.

APPROACH

Brody School of Medicine redesigned its curriculum to prepare leaders to effect health system change. This included development of a distinction track in health system transformation and leadership, known as the Leaders in INnovative Care (LINC) Scholars Program. Selected LINC scholars spend eight weeks in a summer immersion experience designed to provide foundational knowledge and practical application.

OUTCOMES

Two cohorts (15 LINC scholars) completed the summer immersion in 2015 and 2016. Participants demonstrated significant improvement in knowledge and confidence and continue to be engaged in ongoing QI projects throughout the health system. All scholars have presented their work at local, regional, or national meetings. Students rated patient navigation experiences, health system leader interviews, QI project application, and interprofessional experiences as most valuable and recommended adoption in the curriculum for all students.

NEXT STEPS

A distinction track with an immersion component can be an effective method to pilot innovative HSS components for the entire curriculum while preparing a cadre of learners with advanced expertise. To longitudinally measure HSS knowledge change, behavioral impact, and organization-level outcomes, next steps must focus on development of workplace-based assessments, establishment of learner portfolios, and longitudinal tracking of student outcomes, including career trajectory.

Providers' Involvement of Parents, Families, and Family Dynamics in Youth Weight Management Programs

Family-based interventions are the current standard for the treatment of pediatric obesity, yet the details of how providers are involving family members, and the barriers to family involvement, are largely unknown. The objective of this study is to describe how providers in pediatric weight management (PWM) involve family members, identify barriers to family involvement, and how they address challenging family dynamics. A cross-sectional survey was administered to PWM centers/clinics and their providers in the United States and Canada. Analyses included descriptive statistics at the participant (N = 71) and clinic/center (N = 47) levels. Providers indicated that they assessed patients and parents’ perspectives, not other family members, motivation, weight/medical history, dietary and activity behaviors, goals, and barriers. Providers also reported that they asked patients’ perspectives about their parents’ aforementioned behaviors, and siblings’ dietary, activity, and sedentary/screen time behaviors, and weight/medical history. Providers reported that the balance between the patient and parent changed as children aged, with more focus given to the child, and less to the parent, as the child grew older. The most frequent barrier to involving family members in treatment included challenging family dynamics. The most challenging family dynamics were divorce/separation and parent-child conflicts. Providers often refer to and rely on mental/behavioral health providers to address barriers to family involvement and challenging family dynamics. Further research is needed to determine adequate provider training and comfort in dealing with family dynamics in treatment, and ways to mitigate barriers to involving families in PWM.

The Teachers of Quality Academy: Evaluation of the Effectiveness and Impact of a Health Systems Science Training Program

This project aimed to evaluate the effectiveness of a faculty development program in health systems science (HSS)-the Teachers of Quality Academy (TQA). Participants in TQA and a comparison group were evaluated before, during, and 1 year after the program using self-perception questionnaires, tests of HSS knowledge, and tracking of academic productivity and career advancement. Among program completers (n = 27), the mean self-assessed ratings of knowledge and skills of HSS topics immediately after the program, as compared to baseline, increased significantly compared to controls (n = 30). Participants demonstrated progressive improvement of self-perceived skills and attitudes, and retention of HSS knowledge, from baseline to completion of the program. Participants also demonstrated substantially higher HSS scholarly productivity, leadership, and career advancement compared to the comparison group. The TQA effectively created a faculty cadre able to role model, teach, and create a curriculum in HSS competencies for medical students, resident physicians, and other health professionals.

The Teachers of Quality Academy: A Learning Community Approach to Preparing Faculty to Teach Health Systems Science

PROBLEM

Although efforts to integrate health systems science (HSS) topics, such as patient safety, quality improvement (QI), interprofessionalism, and population health, into health professions curricula are increasing, the rate of change has been slow.

APPROACH

The Teachers of Quality Academy (TQA), Brody School of Medicine at East Carolina University, was established in January 2014 with the dual goal of preparing faculty to lead frontline clinical transformation while becoming proficient in the pedagogy and curriculum design necessary to prepare students in HSS competencies. The TQA included the completion of the Institute for Healthcare Improvement Open School Basic Certificate in Quality and Safety; participation in six 2-day learning sessions on key HSS topics; completion of a QI project; and participation in three online graduate courses.

OUTCOMES

Twenty-seven faculty from four health science programs completed the program. All completed their QI projects. Nineteen (70%) have been formally engaged in the design and delivery of the medical student curriculum in HSS. Early into their training, TQA participants began to apply new knowledge and skills in HSS to the development of educational initiatives beyond the medical student curriculum.

NEXT STEPS

Important next steps for TQA participants and program planners include further incorporation as faculty advisors and contributors to the full implementation of the longitudinal HSS curriculum; expanded involvement with the Leaders in Innovative Care Scholars student leadership distinction track; continued in-depth evaluation of the impact of TQA participation on patient care, teaching, and role modeling; and the recruitment of the next cohort of TQA participants.

The MATCH Program: Long-Term Obesity Prevention Through a Middle School Based Intervention

BACKGROUND

Motivating Adolescents with Technology to CHOOSE Health™ (MATCH) has been provided for eight years in North Carolina middle schools with high obesity prevalence.

METHODS

Seventh grade teachers in two schools delivered MATCH lessons in 2009, with one control school. In 2013 students were remeasured and completed a health behavior survey. Outcomes include BMI, BMI z-score (zBMI), weight category, and self-reported behaviors. Comparisons used t tests (continuous measures), Fisher's exact test (categorical measures), and linear mixed models (trend between groups).

RESULTS

Of original participants, 104/189 (55%) of MATCH and 117/173 (68%) of control were remeasured. In the control group, retained participants had lower baseline BMI and were higher percent white. Among all participants, zBMI decreased in MATCH (mean change -0.15 with SD = 0.60) and increased in control (mean change 0.04 with SD = 0.52); between groups p = 0.02. In mixed models for the all overweight subgroup, MATCH had a downward trend in zBMI over time that was significantly different from control (slope MATCH -0.0036 versus control 0.0009; p = 0.01). For shifts in weight category: incidence of obesity was lower in MATCH (13%) versus control (39%); remission of overweight to healthy weight was greater in MATCH (40%) versus control (26%). MATCH participants self-reported lower frequency of intake of sweetened beverages and snacks and hours of weekday TV time than control students.

CONCLUSIONS

MATCH participation can result in long-term prevention of obesity compared to control, with differences in self-reported health behavior changes to support an underlying mechanism for the observed BMI differences.

Physical Examination Findings Among Children and Adolescents With Obesity: An Evidence-Based Review

Overweight and obesity affects 1 in 3 US children and adolescents. Clinical recommendations have largely focused on screening guidelines and counseling strategies. However, the physical examination of the child or adolescent with obesity can provide the clinician with additional information to guide management decisions. This expert-based review focuses on physical examination findings specific to children and adolescents with obesity. For each physical examination element, the authors define the finding and its prevalence among pediatric patients with obesity, discuss the importance and relevance of the finding, describe known techniques to assess severity, and review evidence regarding the need for additional evaluation. The recommendations presented represent a comprehensive review of current evidence as well as expert opinion. The goal of this review is to highlight the importance of conducting a targeted physical examination during pediatric weight management visits.

Addressing Childhood Obesity: Opportunities for Prevention

The overweight and obesity epidemic among children and adolescents in the United States continues to worsen, with notable racial, ethnic, and socioeconomic disparities. Risk factors for pediatric obesity include genetics; environmental and neighborhood factors; increased intake of sugar-sweetened beverages (SSBs), fast-food, and processed snacks; decreased physical activity; shorter sleep duration; and increased personal, prenatal, or family stress. Pediatricians can help prevent obesity by measuring body mass index at least yearly and providing age- and development-appropriate anticipatory guidance to families. Public policies and environmental interventions aim to make it easier for children to make healthy nutrition and physical activity choices. Interventions focused on family habits and parenting strategies have also been successful at preventing or treating childhood obesity.

Improved Body Mass Index Measures Following a Middle School-Based Obesity Intervention-The MATCH Program

BACKGROUND

Motivating Adolescents with Technology to CHOOSE Health™ (MATCH) is an educational and behavioral intervention in seventh grade.

METHODS

Teachers in 2 schools delivered the MATCH curriculum, with 1 control school. Using a quasi-experimental design, outcome measures included lessons completed, body mass index (BMI), BMI z-score (zBMI), BMI percentile, weight category, and self-reported lifestyle behaviors. We used multiple regression models to compare group results.

RESULTS

For the MATCH group (N = 189), teachers provided lessons over 14 weeks; the control group (N = 173) received usual curriculum. Postintervention, the MATCH group had significant decreases in BMI measures compared with the control. In combined overweight and obese participants, the mean (95% confidence interval) zBMI change was -0.05 (-0.07, -0.03) in MATCH and -0.01 (-0.04, 0.02) in control, p = .034 between groups. After 1 year, improvements are sustained: for the overweight subgroup, the mean zBMI decreased from 1.34 to 1.26 post-MATCH, then to 1.26 after 1 year; for the obese subgroup, mean zBMI = 2.16, to 2.13 post-MATCH to 2.08 after 1 year. Self-reported lifestyle behaviors showed no differences.

CONCLUSIONS

MATCH integrates theory-based strategies into standard curriculum delivered by teachers. No prior middle-school intervention has shown sustained change in BMI measures. MATCH warrants further study as a strategy to address obesity.

Predictors of follow-up for overweight youth and parents

Attrition is a significant problem for health care providers working with youth and parents involved in childhood obesity treatment. Barriers for families in childhood obesity treatment have been explored, but less is known about factors that may be associated with follow-up attendance. The purpose of this study is to explore youth and parent variables, pediatrician's evaluations of youth and parents' likelihood to change (LTC), and their association with attendance at follow-up. One hundred ninety-three youth and parent dyads were included in the sample; slightly more than half of the sample did not return for a follow up visit. Descriptive statistics, paired and independent t tests, and correlations were used to determine associations between youth and parent demographic factors, attendance at follow-up, and pediatricians' evaluation of likelihood to change. Evaluations of LTC and demographic factors did not significantly associate with follow-up appointment attendance. Single parents were more likely to be rated by pediatricians as likely to make changes. Implications for future research and clinical practice are discussed.

Adoption of cardiovascular risk reduction guidelines: a cluster-randomized trial

BACKGROUND AND OBJECTIVES

Cardiovascular disease (CVD) and underlying atherosclerosis begin in childhood and are related to CVD risk factors. This study evaluates tools and strategies to enhance adoption of new CVD risk reduction guidelines for children.

METHODS

Thirty-two practices, recruited and supported by 2 primary care research networks, were cluster randomized to a multifaceted controlled intervention. Practices were compared with guideline-based individual and composite measures for BMI, blood pressure (BP), and tobacco. Composite measures were constructed by summing the numerators and denominators of individual measures. Preintervention and postintervention measures were assessed by medical record review of children ages 3 to 11 years. Changes in measures (pre-post and intervention versus control) were compared.

RESULTS

The intervention group BP composite improved by 29.5%, increasing from 49.7% to 79.2%, compared with the control group (49.5% to 49.6%; P < .001). Intervention group BP interpretation improved by 61.1% (from 0.2% to 61.3%), compared with the control group (0.4% to 0.6%; P < .001). The assessment of tobacco exposure or use for 5- to 11-year-olds in the intervention group improved by 30.3% (from 3.4% to 49.1%) versus the control group (0.6% to 21.4%) (P = .042). No significant change was seen in the BMI or tobacco composites measures. The overall composite of 9 measures improved by 13.4% (from 48.2% to 69.8%) for the intervention group versus the control group (47.4% to 55.2%) (P = .01).

CONCLUSIONS

Significant improvement was demonstrated in the overall composite measure, the composite measure of BP, and tobacco assessment and advice for children aged 5 to 11 years.

Education in Quality Improvement for Pediatric Practice: an online program to teach clinicians QI

BACKGROUND

Education in Quality Improvement for Pediatric Practice (EQIPP) is an online program designed to improve evidence-based care delivery by teaching front-line clinicians quality improvement (QI) skills. Our objective was to evaluate EQIPP data to characterize 1) participant enrollment, use patterns, and demographics; 2) changes in performance in clinical QI measures from baseline to follow-up measurement; and 3) participant experience.

METHODS

We conducted an observational study of EQIPP participants utilizing 1 of 3 modules (asthma, immunizations, gastroesophageal reflux disease) from 2009 to 2013. Enrollment and use, demographic, and quality measure data were extracted directly from the EQIPP system; participant experience was assessed via an optional online survey.

RESULTS

Study participants (n = 3501) were diverse in their gender, age, and race; most were board certified. Significant quality gaps were observed across many of the quality measures at baseline; sizable improvements were observed across most quality measures at follow-up. Participants were generally satisfied with their experience. The most influential module elements were collecting and analyzing data, creating and implementing aim statements and improvement plans, and completing "QI Basics."

CONCLUSIONS

Online educational programs, such as EQIPP, hold promise for front-line clinicians to learn QI. The sustainability of the observed improvements in care processes and their linkage to improvements in health outcomes are unknown and are an essential topic for future study.

Long-term obesity prevention and the Motivating Adolescents with Technology to CHOOSE Health™ program

BACKGROUND

The Motivating Adolescents with Technology to CHOOSE Health™ (MATCH) intervention integrates lifestyle behavior change curriculum within academic subjects taught in seventh grade. This study assesses obesity prevention in participants into high school.

METHODS

The study compares four- to five-year longitudinal data from a single-site cohort (N=106, 54% retained from 195 participants at baseline; 82% of those still at the school) pre- and postintervention in a rural middle school with high obesity rates with data from the 2006 Child Survey and 2010 Child and Young Adult Surveys from the National Longitudinal Survey of Youth 1979 (N=600), which serves as a nationally representative comparison group. Outcome measures include pre- and postchanges in weight category, BMI, BMI z-score, BMI percentile for age and gender, and rates of change per month in BMI measures.

RESULTS

At follow-up, change in percent overweight was significantly different between groups, with the MATCH group decreasing (20-12%) and the comparison group increasing (17-19%). Overall, the MATCH group had significantly higher decrease rates in BMI z-scores (p=0.002) and BMI percentile (p=0.01) than the comparison group. Of all adolescents at healthy weight at baseline, 2% from MATCH became overweight after five years, whereas 13% of the comparison group increased to overweight or obese (p=0.02) after four years.

CONCLUSIONS

Despite a small sample size and a high-risk setting, at long-term follow-up, a greater proportion of MATCH participants than in the comparison group decreased from overweight to healthy weight or remained at healthy weight. The MATCH results suggest that some proportion of high-risk adolescents can have their growth trajectory follow a healthier path than expected.

Implementation of the NHLBI integrated guidelines for cardiovascular health and risk reduction in children and adolescents: rationale and study design for young hearts, strong starts, a cluster-randomized trial targeting body mass index, blood pressure, and tobacco

BACKGROUND

Cardiovascular disease (CVD) and the underlying atherosclerosis begin in childhood, and their presence and intensity are related to known cardiovascular disease risk factors. Attention to risk factor control in childhood has the potential to reduce subsequent risk of CVD.

OBJECTIVE

The Young Hearts Strong Starts Study was designed to test strategies facilitating adoption of the National, Heart, Lung and Blood Institute supported Integrated Guidelines for Cardiovascular Health and Risk Reduction in Children and Adolescents. This study compares guideline-based quality measures for body mass index, blood pressure, and tobacco using two strategies: a multifaceted, practice-directed intervention versus standard dissemination.

STUDY DESIGN

Two primary care research networks recruited practices and provided support for the intervention and outcome evaluations. Individual practices were randomly assigned to the intervention or control groups using a cluster randomized design based on network affiliation, number of clinicians per practice, urban versus nonurban location, and practice type. The units of observation are individual children because measure adherence is abstracted from individual patient's medical records. The units of randomization are physician practices. This results in a multilevel design in which patients are nested within practices. The intervention practices received toolkits and supported guideline implementation including academic detailing, an ongoing e-learning group. This project is aligned with the American Board of Pediatrics Maintenance of Certification requirements including monthly physician self-abstraction, webinars, and other elements of the trial.

SIGNIFICANCE

This trial will provide an opportunity to demonstrate tools and strategies to enhance CV prevention in children by guideline-based interventions.

Comparison of predictive equations and measured resting energy expenditure among obese youth attending a pediatric healthy weight clinic: one size does not fit all

BACKGROUND

The Academy of Nutrition and Dietetics recommends the use of indirect calorimetry for calculating caloric targets for weight loss in obese youth. Practitioners typically use predictive equations since indirect calorimetry is often not available. The objective of this study was to compare measured resting energy expenditure (MREE) with that estimated using published predictive equations in obese pediatric patients.

MATERIAL AND METHODS

Youth aged 7 to 18 years (n = 80) who were referred to a university-based healthy weight clinic and who were greater than the 95th percentile BMI for age and gender participated. MREE was measured via a portable indirect calorimeter. Predicted energy expenditure (pEE) was estimated using published equations including those commonly used in children. pEE was compared to the MREE for each subject. Absolute mean difference between MREE and pEE, mean percentage accuracy, and mean error were determined.

RESULTS

Mean percentage accuracy of pEE compared with MREE varied widely, with the Harris-Benedict, Lazzer, and Molnar equations providing the greatest accuracy (65%, 61%, and 60%, respectively). Mean differences between MREE and equation-estimated caloric targets varied from 197.9 kcal/day to 307.7 kcal/day.

CONCLUSIONS

The potential to either overestimate or underestimate calorie needs in the clinical setting is significant when comparing EE derived from predictive equations with that measured using portable indirect calorimetry. While our findings suggest that the Harris-Benedict equation has improved accuracy relative to other equations in severely obese youth, the potential for error remains sufficiently great to suggest that indirect calorimetry is preferred.

Quality of life and BMI changes in youth participating in an integrated pediatric obesity treatment program

BACKGROUND

Changes in Quality of Life (QOL) measures over time with treatment of obesity have not previously been described for youth. We describe the changes from baseline through two follow up visits in youth QOL (assessed by the Pediatric Quality Life Inventory, PedsQL4.0), teen depression (assessed by the Patient Health Questionnaire, PHQ9A), Body Mass Index (BMI) and BMI z-score. We also report caregiver proxy ratings of youth QOL.

METHODS

A sample of 267 pairs of youth and caregiver participants were recruited at their first visit to an outpatient weight-treatment clinic that provides care integrated between a physician, dietician, and mental health provider; of the 267, 113 attended a visit two (V2) follow-up appointment, and 48 attended visit three (V3). We investigated multiple factors longitudinally experienced by youth who are overweight and their caregivers across up to three different integrated care visits. We determined relationships at baseline in QOL, PHQ9A, and BMI z-score, as well as changes in variables over time using linear mixed models with time as a covariate.

RESULTS

Overall across three visits the results indicate that youth had slight declines in relative BMI, significant increases in their QOL and improvements in depression.

CONCLUSIONS

We encourage clinicians and researchers to track youth longitudinally throughout treatment to investigate not only youth's BMI changes, but also psychosocial changes including QOL.

Outcomes from a medical weight loss program: primary care clinics versus weight loss clinics

BACKGROUND

Few studies have focused on weight loss programs implemented in community-based primary care settings. The objective of this analysis was to evaluate the effectiveness of a weight loss program and determine whether physicians in primary care practices could achieve reductions in body weight and body fat similar to those obtained in weight loss clinics.

METHODS

Analyses were performed on chart review data from 413 obese participants who underwent weight loss at a primary care (n=234) or weight loss (n=179) clinic. Participants received physician-guided behavioral modification sessions and self-selected a diet plan partially or fully supplemented by meal replacements. A repeated-measures analysis of covariance was conducted with age and sex serving as covariates; significance was set at P≤.05.

RESULTS

In 178 subjects (43%) completing 12 weeks of the program, primary care clinics were as effective as weight loss clinics at achieving reductions in body weight (12.4 vs 12.1 kg) but better with regard to reduction in body fat percentage (3.8% vs 2.7%; P≤.05). Regardless of location, participants completing 12 weeks lost an average of 11.1% of their body weight. Participants selecting full meal replacement had greater reductions in weight and body fat percentage (12.7 kg, 3.5%) compared with participants selecting a partial meal replacement plan (8.3 kg, 2.3%).

CONCLUSION

Primary care physicians can successfully manage and treat obese patients using behavioral modification techniques coupled with meal replacement diets.

Development and validation of a tool for assessing glucose impairment in adolescents

Introduction

Childhood obesity is associated with an increased risk for type 2 diabetes. Early identification of adolescents at risk for impaired fasting blood glucose may lead to earlier and more comprehensive evaluation and intervention. Because widespread blood glucose testing of adolescents is not recommended, community-based tools are needed to identify those who could benefit from further testing. One such tool, developed for adults, was the Tool for Assessing Glucose ImpairmenT (TAG-IT). Our objective was to validate whether a similar tool could be useful for community-based screening of glucose impairment risk among adolescents.

Methods

Our study sample consisted of 3,050 adolescents aged 12 to18 years who had participated in the 1999-2008 National Health and Nutrition Examination Survey (NHANES). Half of participants were female and 40% were nonwhite. NHANES measured fasting blood glucose and height, weight, and resting heart rate. We used Pearson correlations and regression analysis to determine key variables for predicting glucose impairment. From these measurements, we created a composite TAG-IT score for adolescents called TAG-IT-A. We then applied the TAG-IT-A model to 1988-1994 NHANES data, using linear regression analysis and receiver operating characteristic analysis to determine how well the TAG-IT-A score predicted a fasting blood glucose at or above 100 mg/dL.

Results

We determined that age, sex, body mass index, and resting heart rate were predictors of impaired fasting blood glucose and that TAG-IT-A was a better predictor of impaired fasting blood glucose than body mass index alone (area under the curve, 0.61, P < .001 vs 0.55, P = .10, respectively). A TAG-IT-A score of 3 or higher correctly identified 50% of adolescents with impaired fasting blood glucose, while a score of 5 or higher correctly identified 76% .

Conclusion

The TAG-IT-A score is a simple screening tool that clinicians and public health professionals could use to easily identify adolescents who may have impaired fasting blood glucose and need a more comprehensive evaluation.

A biopsychosocial pilot study of overweight youth and care providers' perceptions of quality of life

This pilot study examined the relationship between youth and care provider self-reports of depressive symptoms assessed through the Patient Health Questionnaire and reports of youth physical and psychosocial functioning assessed by PedsQL4.0 in a rural outpatient overweight pediatric population (N = 66 child and care provider pairs). The relationship between youth body mass index (BMI), youth and care provider depression, youth quality of life (QOL), care provider perception of youth QOL, and youth and care provider congruence of QOL perceptions was examined. Paired t tests were completed to assess the differences between QOL scores for youth and care providers for subgroups based on age, age and gender, and age and race. The mean age of youth participants was 11.9 years; youth BMI ranged from 26.76 to 54.10 (M = 37.20). Our results showed that there are significant differences in youth and care providers' perceptions of QOL when specific demographic categories are assessed by age, gender, and race.

Using clinical skills exams to evaluate medical student skills in prevention

BACKGROUND

In 2006, the Brody School of Medicine Regional Medicine-Public Health Education Center integrated the teaching of prevention into the curriculum for first-, second-, and third-year medical students.

PURPOSE

The purpose of this article is to report on the use of clinical skills exams (CSEs) in the evaluation of prevention health instruction for the period 2006-2010.

METHODS

Two CSEs were employed to measure preventive skills at the end of the third year of medical school. CSE-1 was a woman aged 56 years with knee pain. The outcome measure is the percentage of students asking three or more prevention history items. CSE-2 was a boy, aged 15 years, undergoing a sports physical/preventive screening. The outcome measure is the number of prevention items queried.

RESULTS

For CSE-1, the percentage of students who met the outcome measure increased to 83% in 2010 as compared to 62% in both 2009 and 2007. The improvement between 2007 and 2010 was significant with a p=0.0080 (Fisher's exact test). Of the 64 students taking the third-year medical student objective structured clinical examination-2 in June 2009, the greatest number queried the following preventive items: exercise (98%), alcohol misuse (98%), drug use (98%), school and grades (98%), sexual activity (98%), and tobacco use (97%).

CONCLUSIONS

By integrating prevention elements into CSE cases, the results are useful for student assessment and may be a powerful influence on curricular design, leading to an increase in prevention content.

Prevention and treatment of childhood obesity: care received by a state medicaid population

Based on chart review for a representative cluster sample of North Carolina Medicaid enrollees aged 3 to 5 years (n = 1951) and 13 to 16 years (n = 1922) years, this study describes prevalence, practice patterns, and comorbidities related to overweight/obese immediately prior to 2007 Expert Recommendations. In total, 16% of children in both age groups were overweight, and 20% (ages 3-5 years) and 25% (ages 13-16 years) were obese. For 3- to 5-year-olds, body mass index percentile was infrequently recorded (22%) or plotted on growth charts (24%), and weight status category was rarely documented (10%). Results were similar for adolescents (21%, 20%, and 12%, respectively). In both groups, documentation of counseling in nutrition or physical activity was rare (16% for ages 3-5 years; 7% for ages 13-16 years). In adolescents, approximately 20% received recommended laboratory screening and overweight/ obesity was significantly associated with chart-documented asthma, back pain, prediabetes, gastroesophageal reflux disease, hypertension, and sleep apnea. Whether improvements in documentation of care followed these new guidelines deserves further research.

Short-term change in body mass index in overweight adolescents following cholesterol screening

OBJECTIVE

To determine the relationship between routine screening for cholesterol level and subsequent change in body mass index (BMI; calculated as weight in kilograms divided by height in meters squared).

DESIGN

Retrospective cohort.

SETTING

General pediatrics clinics at 2 academic centers.

PARTICIPANTS

Adolescents with BMIs in the 85th percentile or higher aged 10 to 18 years whose cholesterol levels were screened between June 2003 and June 2005 and controls matched for age, sex, ethnicity, and BMI. Main Exposure Cholesterol screening.

OUTCOME MEASURES

The primary outcome was the "best" individual BMI change following screening. The secondary outcome was the trend of BMI change during follow-up.

RESULTS

Sixty-four matched pairs met the inclusion criteria (N = 128). Subjects were followed up for 3 to 30 months after identification (mean [SD], 18 [8] months). The mean BMI changes for screened subjects did not differ from those of unscreened subjects (-0.33 vs -0.34; P = .97). However, age at time of enrollment significantly modified the results (P = .02). After cholesterol screening, younger subjects initially increased in BMI, while older subjects initially decreased. The overall trend of individual BMI change increased during the follow-up period and was not significantly different between the 2 groups (likelihood ratio test, 0.9; P = .64).

CONCLUSIONS

Cholesterol screening of overweight and obese adolescents is not associated with short-term BMI change, though age at time of screening modified subsequent BMI change. Clinicians should not assume that screening will help motivate weight loss, though the effect of age at the time of screening deserves further research.

Bolstering confidence in obesity prevention and treatment counseling for resident and community pediatricians

OBJECTIVE

To assess whether equipping resident pediatricians and community pediatricians with both training and practical tools improves their perceived confidence, ease, and frequency of obesity-related counseling to patients.

METHODS

In 2005-2006, resident pediatricians (n = 49) and community pediatricians (n = 18) received training regarding three evidence-based obesity prevention/treatment tools and responded to pre- and post-intervention questionnaires. We analyzed changes in reported mean confidence, ease, and frequency of dietary, physical activity, and weight status counseling.

RESULTS

Baseline scores of confidence, ease, and frequency of counseling were higher in community pediatricians than residents. Mean scores increased significantly in the combined group, among residents only, and trended towards improvement in the community pediatricians following the intervention. Means for "control" questions were unchanged.

CONCLUSION

Training and tools for residents and community pediatricians improved their confidence, ease, and frequency of obesity-related counseling.

PRACTICE IMPLICATIONS

This study demonstrates that when feasible and appropriate tools and training were provided through a simple intervention, physicians gained confidence and ease and increased their counseling frequency. The results here suggest that widespread implementation of such educational interventions for community practitioners and practitioners in training could change the way physicians counsel patients to prevent the often frustrating problem of childhood obesity.

Structured intervention utilizing state professional societies to foster quality improvement in practice

INTRODUCTION

Despite the existence of guidelines for attention deficit hyperactivity disorder (ADHD), clinical practices vary substantially. Practitioners can apply quality improvement (QI) strategies to adapt office processes and clinical practice towards evidence-based care. We identified facilitators and barriers to participation in a professional society-led structured collaborative to learn QI methods and improve care.

METHODS

Ten chapters of the American Academy of Pediatrics participated in the effort. Support to chapter leaders included conference calls, listserv, technical support, and data aggregation. Support from the chapters to participating pediatricians included online continuing medical education modules, a workshop, chart reviews, and QI coaching. Qualitative data were obtained through interviews of 22 project leaders and reviews of project progress reports. Quantitative results were obtained from surveys of 186 physician participants. Outcomes included facilitators/barriers to program implementation, evidence for sustained chapter QI infrastructure, and participant assessment of improvements in care.

RESULTS

Facilitators included physician opinion leaders, a workshop, conference calls, QI support, and opportunities for shared learning. Barriers included lack of time, competing clinical priorities, challenges of using the online module, and underutilization of listservs. Seven chapters planned ongoing activities around attention deficit hyperactivity disorder (ADHD), eight had specific plans to use QI infrastructure for additional clinical topics, and three developed significant QI infrastructure. Physicians believed care improved.

DISCUSSION

As requirements grow for participation in QI for maintenance of certification, national and state-level professional societies are interested in and can develop infrastructure to support quality improvement. Coaching, tools, and support from the national organization and QI experts are helpful in facilitating efforts.

Violence during pregnancy: measurement issues

OBJECTIVES

Standardized quantitative methods are needed to study occurrence and timing of violence in relation to pregnancy and to study the context in which pregnancy-related violence occurs.

METHODS

Data from three published studies of prevalence of violence during pregnancy are used to illustrate ways to measure the association of violence in relation to pregnancy.

RESULTS

Four patterns of violence in relation to pregnancy are identified, and related research issues are discussed. Also, 2 population-based surveys that address the suggestions presented here are discussed.

CONCLUSIONS

Better measurement of the association between violence and pregnancy will facilitate development of data-based prevention and intervention programs.

Prevalence of violence against pregnant women

OBJECTIVES

To summarize the methods and findings of studies examining the prevalence of violence against pregnant women and to synthesize these findings by comparing study characteristics for studies with similar and dissimilar results.

DATA SOURCES

MEDLINE, POPLINE, Psychological Abstracts, and Sociological Abstracts databases were searched for all articles pertaining to violence during pregnancy for the period 1963 through August 1995.

STUDY SELECTION

Thirteen studies were selected on the basis of specific criteria: a sample with initially unknown violence status; a clear statement of research question(s), with focus on measuring the prevalence of violence; descriptions of the sample, data source, and data collection methods; and data from the United States or another developed country.

DATA EXTRACTION

Relevant data were extracted to compare studies by study description, methods, and results.

DATA SYNTHESIS

Evidence from the studies we reviewed indicates that the prevalence of violence during pregnancy ranges from 0.9% to 20.1%. Measures of violence, populations sampled, and study methods varied considerably across studies, and these factors may affect prevalence estimates. Studies that asked about violence more than once during detailed in-person interviews or asked later in pregnancy (during the third trimester) reported higher prevalence rates (7.4%-20.1%). The lowest estimate was reported by women who attended a private clinic and responded to a self-administered questionnaire provided to them by a person who was not a health care provider.

CONCLUSIONS

Violence may be a more common problem for pregnant women than some conditions for which they are routinely screened and evaluated. Future research that more accurately measures physical violence during pregnancy would contribute to more effective design and implementation of prevention and intervention strategies.

Emergency triage to intensive care: can we use prognosis and patient preferences?

OBJECTIVE

To identify predictors of 6-month mortality known before emergent admission to intensive care (IC) and to describe obstacles to the use of patient preferences in emergency triage decisions.

DESIGN

Historical cohort.

SETTING

A 600-bed university hospital.

PATIENTS

263 consecutive patients triaged in the emergency room to receive intensive care.

MEASUREMENTS AND MAIN RESULTS

Medical records were abstracted for age, performance status, and chronic disease severity as predictors of 6-month survival. Acute Physiology Score (APS) in the emergency room was used as a measure of acute illness severity. Deaths during the 6 months following IC admission were determined from record review and death certificate data. Obstacles to communication of patient treatment preferences at the time of triage were described. Six-month mortality was 19 percent, and increased with increasing APS, age > or = 80 (43%), poor performance status (56%), and severe chronic disease (33%) (P < or = 0.01). In multivariate analysis, APS, age > or = 80 and performance status were independent predictors of 6-month mortality. Only APS predicted mortality in hospital. The most common obstacles to use of patient preferences in triage decisions were absence of documented advance directives (95%) and the brief duration of acute illness (72%). Mental status changes were very common in the emergency room for nonsurvivors (61%), but chronic cognitive impairment was rare (3%).

CONCLUSIONS

Patients with poor performance status or very advanced age have increased mortality within 6 months of emergent triage to IC. Mental status changes, absence of advance directives, and time constraints are common barriers to communication of patient preferences at the time of triage. Primary care physicians need to elicit and record patients' preferences before the time of emergent decisions about IC.

Regulation of cytokine production in the human thymus: epidermal growth factor and transforming growth factor alpha regulate mRNA levels of interleukin 1 alpha (IL-1 alpha), IL-1 beta, and IL-6 in human thymic epithelial cells at a post-transcriptional level

Human thymic epithelial (TE) cells produce interleukin 1 alpha (IL-1 alpha), IL-1 beta, and IL-6, cytokines that are important for thymocyte proliferation. The mRNAs for these cytokines are short-lived and are inducible by multiple stimuli. Thus, the steady-state levels for IL-1 and IL-6 mRNAs are critical in establishing the final cytokine protein levels. In this study we have evaluated the effect of epidermal growth factor (EGF), a growth factor for TE cells, and its homologue transforming growth factor alpha (TGF-alpha), on primary cultures of normal human TE cells for the levels of IL-1 alpha, IL-1 beta, IL-6, and TGF-alpha mRNA. We showed that TE cells expressed EGF receptors (EGF-R) in vitro and in vivo, and that treatment of TE cells with EGF or TGF-alpha increased IL-1 and IL-6 biological activity and mRNA levels for IL-1 alpha, IL-1 beta, and IL-6. Neither EGF nor TGF-alpha increased transcription rates of IL-1 alpha, IL-1 beta, and IL-6 genes, but rather both EGF and TGF-alpha increased cytokine mRNA stability. By indirect immunofluorescence assay, TGF-alpha was localized in medullary TE cells and thymic Hassall's bodies while EGF-R was localized to TE cells throughout the thymus. Thus, TGF-alpha and EGF are critical regulatory molecules for production of TE cell-derived cytokines within the thymus and may function as key modulators of human T cell development in vivo.

Human thymic epithelial cells produce IL-6, granulocyte-monocyte-CSF, and leukemia inhibitory factor

The development of conditions for culturing normal human thymic epithelial (TE) cells free from contaminating stromal cells has allowed us to characterize a number of cytokines produced by TE cells. Using cDNA probes for human IL-6, granulocyte-monocyte-CSF, and leukemia inhibitory factor (LIF), we identified mRNA for these cytokines by RNA blot analysis of total RNA preparations derived from TE cells. We demonstrated that TE cells produced IL-6 transcripts and that TE cell culture supernatants contained IL-6 biologic activity, as determined by the ability to support proliferation of the T1165 plasmacytoma line. The 1.0-kilobase (kb) transcript of granulocyte-monocyte-CSF was also detected in TE cell-derived total RNA. TE cell culture supernatants contained LIF activity, as determined by proliferation of the murine cell line DA-1a, and a 4.0-kb LIF transcript was detected in TE cell-derived total RNA preparations. The 4.0-kb LIF transcript from TE cell-derived total RNA corresponded in size to the LIF transcripts in PMA-activated T lymphocytes. Thus, using biologic assays and RNA blot analysis, we demonstrated that cultured normal human TE cells produced both immunoregulatory cytokines and cytokines that drive various differentiation stages of human hematopoiesis. Our findings support the hypothesis that TE cells may play a role in providing cytokines that are important for the proliferation and differentiation of hematopoietic precursor cells that migrate to the thymus during fetal and postnatal human thymic development.

Human thymic epithelial cells produce IL-6, granulocyte-monocyte-CSF, and leukemia inhibitory factor

The development of conditions for culturing normal human thymic epithelial (TE) cells free from contaminating stromal cells has allowed us to characterize a number of cytokines produced by TE cells. Using cDNA probes for human IL-6, granulocyte-monocyte-CSF, and leukemia inhibitory factor (LIF), we identified mRNA for these cytokines by RNA blot analysis of total RNA preparations derived from TE cells. We demonstrated that TE cells produced IL-6 transcripts and that TE cell culture supernatants contained IL-6 biologic activity, as determined by the ability to support proliferation of the T1165 plasmacytoma line. The 1.0-kilobase (kb) transcript of granulocyte-monocyte-CSF was also detected in TE cell-derived total RNA. TE cell culture supernatants contained LIF activity, as determined by proliferation of the murine cell line DA-1a, and a 4.0-kb LIF transcript was detected in TE cell-derived total RNA preparations. The 4.0-kb LIF transcript from TE cell-derived total RNA corresponded in size to the LIF transcripts in PMA-activated T lymphocytes. Thus, using biologic assays and RNA blot analysis, we demonstrated that cultured normal human TE cells produced both immunoregulatory cytokines and cytokines that drive various differentiation stages of human hematopoiesis. Our findings support the hypothesis that TE cells may play a role in providing cytokines that are important for the proliferation and differentiation of hematopoietic precursor cells that migrate to the thymus during fetal and postnatal human thymic development.