95th Percentile Research Articles

The risk of hospitalization associated with hot nights and excess nighttime heat in a subtropical metropolis: a time-series study in Hong Kong, 2000–2019

Recent studies showed increased mortality risks after hot nights, but their effect on hospitalizations, especially in vulnerable populations, remains under-studied. Daily hospitalization, meteorological (including hourly), and air pollution data were collected for the hot seasons (May-October) of 2000-19 in Hong Kong. We derived three hot-night metrics: HNday28 °C, daily minimum temperature ≥28°C, the governmental definition of hot nights; HNe, hot night excess calculated by summing heat excess of hourly temperatures above 28°C at night; and HNday90th, hot nights classified using the 90th percentile HNe (17.7°C⋅h) as a cutoff. We fitted time-series regression with distributed lag nonlinear models to examine the associations of hot-night metrics with various hospitalizations. During the 3680 study days, 5,002,114 non-cancer non-external (NCNE) hospitalizations were recorded. Half (1874) of the days experienced excess nighttime heat (HNe>0) with a mean (SD) of 8.0 (6.8) °C⋅h; 499 and 187 hot nights were identified by HNday28 °C and HNday90th, respectively. Extreme HNe (99th percentile vs 0°C⋅h) was significantly associated with increased NCNE hospitalizations over lag 0-4 days by 3.1% [95% confidence interval: 1.5%, 4.8%] overall, with enhanced effects in elderly (5.3% [3.2%, 7.4%]), low-SES individuals (5.3% [2.8%, 8.0%]), and circulatory admissions (3.4% [0.2%, 6.8%]). HNday90th, reflecting extreme HNe, better identified hazardous hot nights than the official HNday28 °C. Excessive nighttime heat is significantly associated with increased hospitalizations, particularly affecting the elderly and socioeconomically disadvantaged individuals. Nighttime heat intensity should be incorporated in defining hot nights with public health relevance. British Heart Foundation.

Coagulation profiles and percentiles in neonates with hypoxic-ischemic encephalopathy undergoing therapeutic hypothermia: A step toward more accurate transfusion thresholds.

In the literature, there are no studies about the transfusion threshold for neonates with hypoxic-ischemic encephalopathy (HIE) undergoing therapeutic hypothermia (TH). In order to facilitate accurate interpretation of coagulation results in these neonates, we aimed to generate specific reference intervals in this specific population. This retrospective study included all HIE neonates admitted from 2014 to 2022 to undergo TH. All infants during TH underwent blood exams, including the coagulation profile. Our primary outcome was to assess the estimates of the 3rd, 10th, 25th, 50th, 75th, 90th, and 97th percentiles for each parameter on admission (before transfusion). By the receiver operating characteristic (ROC) analysis, the area under the ROC curve (AUC) and the best cut-off point were used to evaluate the ability of the prothrombin time expressed as international normalized ratio (PT-INR) to predict the risk of any bleeding. A total of 143 infants were included in this study. On admission, the median fibrinogen value was 205mg/dL, prothrombin time 18.6seconds, PT-INR 1.50, activated partial thromboplastin time 38.3seconds, thrombin time 18.6seconds, antithrombin 57.0%. The optimal cut-off of PT-INR in predicting the risk of any bleeding was greater than 1.84 (AUC.623, p=.024). For the first time, we proposed the percentiles of coagulation parameters in our cohort of neonates with HIE. Furthermore, we found that a PT-INR greater than 1.84 can significantly predict the risk of any bleeding. Further studies are needed to determine if a restrictive versus a liberal transfusion approach can be equally safer for these high-risk infants.

Hearing Loss, Hearing Aids, and Cognition.

Most observational studies examining the association between hearing loss (HL) and cognitive impairment used subjective measures of hearing and addressed only one dimension of cognition, and very few investigated the potential benefit of hearing aids (HAs). To evaluate objectively measured HL and several dimensions of cognition and estimate the association with HA use. A cross-sectional analysis of the CONSTANCES cohort study, which recruited participants from January 1, 2012, to December 31, 2020, was conducted. Participants were a representative sample of adults (age, 45-69 years) with audiometric data and cognitive evaluation from 21 preventive health centers in France. Data analysis was conducted from April 1 to September 15, 2023. The main exposure was HL, which was defined by a pure-tone average in the best ear higher than 20 dB hearing level for mild loss and 35 dB hearing level for disabling loss. Secondary exposure was self-reported HA use. Cognition was evaluated at study inclusion by a standardized battery of 5 cognitive tests conducted by trained neuropsychologists. A global cognitive score was computed from principal component analysis and global cognitive impairment was defined as having a score less than or equal to the 25th percentile of the distribution. The study population included 62 072 participants with audiometric data (mean [SD] age, 57.4 [7] years; 52% women). Overall, 38% (n = 23 768) had mild HL, 10% (n = 6012) had disabling HL, and 3% (n = 1668) were HA users. In multivariable analyses, mild HL (odds ratio [OR], 1.10; 95% CI, 1.05-1.15) and disabling HL (OR, 1.24; 95% CI, 1.16-1.33) were associated with greater global cognitive impairment. The odds of cognitive impairment did not differ significantly between all participants with HA use and participants with disabling HL without HAs (OR, 0.94; 95% CI, 0.83-1.07), except among participants with depression (OR, 0.62; 95% CI, 0.44-0.88). In this cohort study, an association between the severity of HL and global cognitive impairment was found. The use of HAs was not associated with significantly lower odds of cognitive impairment. The findings suggest that it may be useful to monitor cognitive function in middle-aged individuals with HL.

Patient-Specific Myocardial Infarction Risk Thresholds From AI-Enabled Coronary Plaque Analysis

BACKGROUND: Plaque quantification from coronary computed tomography angiography has emerged as a valuable predictor of cardiovascular risk. Deep learning can provide automated quantification of coronary plaque from computed tomography angiography. We determined per-patient age- and sex-specific distributions of deep learning–based plaque measurements and further evaluated their risk prediction for myocardial infarction in external samples. METHODS: In this international, multicenter study of 2803 patients, a previously validated deep learning system was used to quantify coronary plaque from computed tomography angiography. Age- and sex-specific distributions of coronary plaque volume were determined from 956 patients undergoing computed tomography angiography for stable coronary artery disease from 5 cohorts. Multicenter external samples were used to evaluate associations between coronary plaque percentiles and myocardial infarction. RESULTS: Quantitative deep learning plaque volumes increased with age and were higher in male patients. In the combined external sample (n=1847), patients in the ≥75th percentile of total plaque volume (unadjusted hazard ratio, 2.65 [95% CI, 1.47–4.78]; P =0.001) were at increased risk of myocardial infarction compared with patients below the 50th percentile. Similar relationships were seen for most plaque volumes and persisted in multivariable analyses adjusting for clinical characteristics, coronary artery calcium, stenosis, and plaque volume, with adjusted hazard ratios ranging from 2.38 to 2.50 for patients in the ≥75th percentile of total plaque volume. CONCLUSIONS: Per-patient age- and sex-specific distributions for deep learning–based coronary plaque volumes are strongly predictive of myocardial infarction, with the highest risk seen in patients with coronary plaque volumes in the ≥75th percentile.

Association of veteran suicide risk with state-level firearm ownership rates and firearm laws in the USA

BackgroundVeterans have higher suicide rates than matched non-veterans, with firearm suicides being especially prevalent among veterans. We examined whether state firearm laws and state firearm ownership rates are important risk...

Improved diagnostic performance of high-sensitivity cardiac troponins in muscle dystrophies using comprehensive definition criteria for cardiac involvement: A longitudinal study on 35 patients.

Sparse information is available on the correct interpretation of elevated high-sensitivity cardiac troponin (hs-cTn) in confirmed muscular dystrophies. Serum concentrations of hs-cTn T (hs-cTnT) and hs-cTn I (hs-cTnI) were determined in 35 stable outpatients with confirmed skeletal muscle dystrophies. We calculated sensitivities, specificities, and positive and negative predictive values of hs-cTnT and hs-cTnI for identification of cardiac involvement using a comprehensive definition that included diastolic left ventricular and right ventricular function, strain analysis using two-dimensional transthoracic echocardiogram and magnetic resonance imaging, myocardial biopsies, and consideration of a variety of triggers for cardiac injury, including arrhythmias, conduction disorders, and hypoxemia due to respiratory failure. Cardiac involvement was diagnosed in 34 of 35 cases. Specificities of hs-cTnT increased from 12.5% to 100% (p = 0.0006) applying the comprehensive definition compared to a definition based on electrocardiography and echocardiography alone. At the recommended 99th percentile upper limit of normal, sensitivities were significantly lower for hs-cTnI than for hs-cTnT (29.4% vs. 100%, p = 0.0164). Conversely, the specificities of hs-cTnT and hs-cTnI increased to 100% when using the comprehensive definition criteria for diagnosing cardiac involvement. Elevated hs-cTnT but not hs-cTnI discriminates cardiac involvement in cases with confirmed skeletal muscle dystrophies with very high sensitivity and 100% specificity. Prior reports on worse performance may be explained by the use of less sensitive imaging methods or incomplete assessment of cardiac involvement.

Modeling aboveground carbon stock under the forest canopy influence

The dominance, size, and sociological position of tree species are essential components of natural forest patterns, providing critical information for understandinh forest dynamics. These patterns can be influenced by a variety of factors. This study aimed to evaluate the effectiveness of using spectral, hydrological, and geographical variables to estimate aboveground carbon stock (AGC) across four canopy strata, defined by diametric percentiles, in a Brazilian Atlantic Forest remnant. Our methodology, which employed machine learning techniques (Random Forest - RF + Genetic Algorithm - GA) and Multiple Linear Regression (MLR) to model AGC, proved to be highly efficient, as evidenced by our results. We observed a wide range of AGC values, from 0.37 to 467.71 MgC.ha-1, with an average of 77.4 MgC.ha-1. Trees in the 30th, 60th, and 90th percentiles contributed, respectively, 97.32%, 87.74%, and 52.02% of the total AGC. Spectral and hydrological variables combined with basal area explain AGC stock. Our findings demonstrate the robustness of machine learning techniques and MLR methods in obtaining accurate carbon estimates and generating an optimized dataset. Trees within the 30th percentile represent a smaller portion of the total AGC, and their removal does not interfere with the relationship between AGC and spectral variables.

Assessing disease progression in ALS: prognostic subgroups and outliers.

Background: The rate of disease progression, measured by the decline of ALS Functional Rating Scale-Revised (ALSFRS-R) from symptom onset to diagnosis (ΔFS) is a well-established prognostic biomarker for predicting survival. Objectives: This study aims to categorize a large patient cohort based on the initial ΔFS and subsequently investigate survival deviations from the expected prognosis defined by ΔFS. Methods: 1056 ALS patients were stratified into three progression categories based on their ΔFS: slow progressors (below 25th percentile), intermediate progressors (between 25th and 75th percentiles), and fast progressors (above 75th percentile). Survival outcomes were classified as short survivors (<2 years), average survivors (2-5 years), and long survivors (>5 years). Clinical and demographic characteristics within each subgroup were then analyzed. Results: ΔFS stratification yielded cutoff values of <0.29, 0.29-1.03, and >1.03 points/month. Long survivors comprised 26% and 21% were short survivors. Six percent of the fast progressors had a life expectancy of more than 5 years, and none of the clinical and demographic characteristics analyzed could fully explain this discrepancy. Conversely, 13% of intermediate progressors lived less than 2 years, according to a short-diagnostic delay in these patients. Discussion: Our study reaffirms ΔFS as a prognostic biomarker for ALS. We disclosed outliers defying anticipated patterns. The observed shift in progression categories underscores the non-linear nature of disease progression. Genetic and unknown biological reasons may explain these deviations. Further research is needed to fully understand modulation of ALS survival.

Demographical and Regional Trends of HIV-Related Mortality Among Young Adults in the United States From 1999-2020.

BackgroundHIV remains a leading cause of death in the U.S. Previous research has examined mortality patterns among older adults with HIV, revealing regional and demographic disparities. This study aims to assess demographic and regional trends in HIV-related mortality among young adults from 1999 to 2020. MethodologyCDC WONDER database was used to identify young adults aged 15-44 where HIV was mentioned as either underlying or contributory cause of mortality between 1999 and 2020, using the B20-B24 codes from the International Statistical Classification of Diseases and Related Health Problems-10th Revision (ICD-10). Age adjusted mortality rates (AAMRs) per 100,000 population and Annual percentage change (APC) were determined. ResultsThe AAMRs for HIV in young adults consistently declined from 1999-2018, followed by a period of stability from 2018-2020 (APC: 0.5%; 95% CI, -7.4 to 9.0), with 64% deaths occurred in medical facilities. Overall, males had a twice AAMR than females (Female: 2.22, 95% CI 2.19-2.24; Male: 5.19, 95% CI 5.15-5.23). Non-Hispanic (NH) Blacks had seven-fold higher mortality rates than Whites (AAMR 14.88 vs. 2.036). The Southern region experienced three-fold higher mortality compared to the Midwest. Metropolitan adults had a two-fold higher AAMR than non-metropolitan adults. States in the top 90th percentile for HIV-related mortality, including Mississippi, Maryland, Florida, Louisiana, and the District of Columbia, exhibited six times higher mortality compared to states in the bottom 10th percentile, such as North Dakota, Idaho, Wyoming, Montana, and Utah. ConclusionTo address these disparities and ensure continued progress, urgent measures are required.

Occurrence of overweight, obesity and their associated risk factors among primary school pupils in Samarra/Iraq: a cross-sectional study.

Objective: To find the prevalence of overweight and obesity and the risk factors for increasing weight amongyoung students. Method: The cross-sectional, descriptive study was conducted during the 2018-19 academic year in Samarra, Iraq,after approval from the ethics review committee of Anbar University, Al Anbar, Iraq, and comprised primaryschoolchildren aged 7-13 years regardless of gender. After collecting sociodemographic data, based on body massindex values, the children were categorised into malnourished &lt;5th percentile, normal 5-84th percentile,overweight 85-97th percentile, and obese greater than or equal to 97th percentile. Data was analysed using SPSS 27. Results: Of the 450 subjects, 243(54%) were girls and 207(46%) were boys. Obesity was found in 54(12%,) subjects,while 83(18.4%) were overweight. Class grades of the schoolchildren, mothers’ education, type of food taken toschool, money to buy from the school canteen, consumption of soft drinks, and eating snacks were significantlyrelated to body mass index percentile (p&lt;0.05). Conclusion: Overweight and obesity were prevalent in school children, and a number of factors contributed to theproblem, highlighting the need for health education interventions. Key Words: Overweight, Snacks, Obesity, Risk Factors, Health, Carbonated, Beverages

Modification of the association between cold spells and cardiovascular disease by changes in natural gas prices: A nationwide time-series study

BackgroundAlthough the association between low ambient temperature and cardiovascular disease (CVD) is well-established, the effect of winter energy prices on this association remains unknown. AimThis ecological study aimed to investigate whether changes in natural gas prices (NGP), which account for a significant portion of winter energy prices in Korea, affect the association of cold spells with hospital admissions and mortality due to CVD. MethodsData from the National Health Insurance Service and Statistics Korea were used to determine the daily number of hospital admissions and mortality rates associated with CVD. From January 2012 to February 2017, the NGP continually increased by 24.1%. From January 2012 to December 2014 the NGP continually decreased by 32.6% owing to the Korea Gas Corporation’s management decisions, independent of external socioeconomic factors. We investigated the differences in the associations between cold spells and CVD-related outcomes in price-increasing and price-decreasing periods using a Poisson regression with a distributed lag nonlinear model. Cold spells were assessed on two consecutive days at the 5th percentile of the temperature for each region. ResultsThe meteorological factors and air pollution levels were similar between the two periods. The association between cold spells and hospital admissions due to CVD was stronger during the price-increasing period than during the price-decreasing period [ratio of cumulative relative risk (RRR) = 1.71, 95% confidence interval (CI): 1.31–2.22]. The difference in the association with mortality due to CVD between the two periods was not significant, although the point estimate remained >1 (RRR = 1.11, 95% CI: 0.90–1.38). ConclusionsChanges in energy prices may modify the cold spell-related CVD risk, possibly by inducing behavioral changes to manage energy expenditure. Policymakers should take into account the potential public health implications of changes in energy prices, alongside their economic effects.

Specific growth velocity reference charts for monochorionic twin pregnancies.

We aimed to create specific growth velocity reference charts for monochorionic (MC) twin pregnancies and provide additional information for assessing fetal growth in MC twins. This retrospective study collected data from uncomplicated MC twins with serial ultrasound parameters. The four ultrasound parameters, including biparietal diameter, femur length, head circumference, and abdominal circumference, were used to calculate the estimated fetal weight (EFW). Multilevel linear regression models were applied to fit growth velocity charts for each biometric parameter and EFW. Analysis of variance was used to examine differences in birthweight by whether EFW velocity and EFW values were <10th or ≥10th percentiles. The final analysis encompassed a total of 5956 ultrasound examinations conducted on 487 MC twins. The growth velocity of four biparietal diameters exhibited a gradual decrease in a nearly linear fashion progressing from 18 to 37 gestational weeks. The EFW velocity increased steadily from 18 to 36 gestational weeks, reaching a peak of 178.2 g/week, and then the velocity gradually decreased until delivery. At 32 weeks for illustration, the lightest birth weight was observed when both EFW and EFW velocity were <10th percentile (1899 g). The study also found that birth weight was higher when EFW velocity was ≥10th percentile compared with <10th percentile, regardless of EFW being below or above the 10th percentile (2263 and 1906 g, respectively; P < 0.001). We developed specific growth velocity reference charts for MC twins, which could provide a valuable reference point for a more precise evaluation of fetal growth in MC twins. Preliminary findings indicate that the inclusion of fetal growth velocity in monitoring fetal growth provides additional information beyond EFW alone.

Factors Affecting Length of Stay for Children Hospitalized After Pediatric Surgical Procedures.

Understanding the postoperative length of stay (LOS) by surgical procedure is important for hospital medicine clinicians involved in surgical co-management. We assessed variation in postoperative LOS for children after elective surgical procedures and risk factors for prolonged LOS. This study is a retrospective analysis of pediatric patients undergoing elective surgical procedures between January 1, 2018 and October 1, 2021 with postoperative hospitalization for recovery at a freestanding children's hospital. The postoperative LOS (number of days) was compared across types of surgery and by the number of chronic conditions (assessed with the Agency for Healthcare Research and Quality Condition Indicator system) using multivariable quantile regression. The median (interquartile range) LOS across all 347 types of surgical procedures combined was 2 (interquartile range 1-4). Surgical procedures (n = 85) with a median LOS between 3.0 and <5.0 days (eg, spinal fusion, Chiari decompression) accounted for 20.9% of all hospitalizations (N = 12 139) and 23.1% of all postoperative bed days. Procedures (n = 46) with a median LOS of ≥5.0 days (eg, femoral osteotomy, bladder reconstruction) accounted for 15.0% and 46.8% of all hospitalizations and bed days, respectively. After controlling for the type of procedure, having ≥4 (versus none) chronic conditions was significantly associated with experiencing a prolonged LOS (90th percentile: 5.2 days); patients with 4 to 6, versus no, chronic conditions stayed a median of 1.4 (95% confidence interval [CI] 0.7-2.2) days longer, those with 7 to 9 chronic conditions stayed a median of 1.9 (95% CI 1.0-2.7) days longer, and those with ≥10 chronic conditions stayed a median of 4.0 (95% CI 3.3-4.7) days longer. Hospital medicine clinicians can use the type of surgery in combination with the number of chronic conditions to estimate postoperative LOS after elective surgical procedures in children.

Fine Motor Impairment and its Impact on Social Outcomes in Survivors of Pediatric Acute Lymphoblastic Leukemia: St Jude Lifetime Cohort Study.

The impact of fine motor impairment among adult survivors of childhood acute lymphoblastic leukemia on life after treatment is unknown. This study evaluated prevalence and utilized multivariate logistic regression to identify risk factors for fine motor impairment among survivors of acute lymphoblastic leukemia, and associations with educational attainment and social independence. Latent class analysis defined social independence (independent, moderately independent, dependent), using employment, independent living, personal care assistance, routine need assistance, driver's license status, and marital status inputs. Among 875 survivors who were ≥ 25years old (age when most adults achieve independence) and ≥ 5years from diagnosis (mean = 28.97years), 33.6% had fine motor impairment, with scores at or below the 10th percentile of the scores of community controls (n = 460) on fine motor components of the Physical Performance Test and the Grooved Peg-Board Test. Survivors exposed to cranial radiation had more fine motor impairment than those without (45.8% vs 20.2%). Male sex (exposed: odds ratio [OR] = 2.55, 95.0% CI = 1.65-3.92; unexposed: OR = 3.02, 95.0% CI = 1.69-5.38), and lower scores on the Wechsler Abbreviated Scale of Intelligence (exposed: OR = 0.46, 95.0% CI = 0.36-0.58; unexposed: OR = 0.43, 95.0% CI = 0.31-0.58) were risk factors for neuropathy. A 1-point-higher total neuropathy score was associated with 8% (95.0% CI = 1%-17%) increased odds of fine motor impairment. Fine motor impairment was associated with less than a college education (less than high school: OR = 2.23, 95.0% CI = 1.20-4.14; high school diploma/general equivalency diploma: OR = 2.66, 95.0% CI = 1.65-4.30; vocational education: OR = 2.07, 95.0% CI = 1.38-3.13), and less social independence (moderately independent: OR = 1.80, 95.0% CI = 1.15-2.83; dependent: OR = 2.65, 95.0% CI = 1.25-5.64). Fine motor impairment in survivors of childhood acute lymphoblastic leukemia may interfere with optimal educational attainment and social independence. Early identification of survivors at risk for fine motor impairment, with timely intervention, may improve long-term outcomes.

Adverse pregnancy outcomes and the abnormal umbilical cord coiling index.

The abnormal umbilical cord coiling index (UCI) may be one of the ways to predict adverse pregnancy outcomes. This study attempted to determine the association between abnormal UCI and maternal, fetal, and neonatal outcomes. This longitudinal study was conducted on 400 women referred for delivery from April to August 2021. UCI was calculated by dividing the total number of coils by the total length of the umbilical cord in centimeters. In eligible cases, the length of the umbilical cord and the number of vascular coils along the total umbilical cord were measured after birth. UCI less than the 10th percentile and more than the 90th percentile was considered abnormal, and between the 10th and 90th percentiles was considered normal. Data were analyzed using SPSS version 20. P < 0.05 were considered statistically significant. The mean length of the umbilical cord was 56.12±8.38 cm, the number of umbilical cord rings was 13.70±3.51, and the UCI was 0.24±0.07. In the regression analysis, women with gestational diabetes had a significant association with abnormal UCI (P = 0.044). Thus, the probability of abnormal UCI was about 3.5 times higher in women with gestational diabetes than in normal pregnancies. Also, the history of stillbirth had a significant association with abnormal UCI (P < 0.05). It is recommended to perform a UCI examination after delivery as part of a neonatal examination to find an explanation for maternal, fetal, and neonatal outcomes.

Application en routine des résultats d’un essai randomisé : performance de l’échographie en pratique courante pour le dépistage de la macrosomie fœtale

Objective : To evaluate the performance of ultrasound at 36 weeks of gestation for screening fetal macrosomia according to the criteria of the randomized “DAME” trial.Méthod : Retrospective observational study over 2 years in a type 3 maternity hospital. The primary outcome was birth weight above the 97th percentile on Audipog birth weight curves. The sensitivity, specificity, positive and negative predictive value of ultrasound at 36 SA for predicting macrosomia were calculated. For each patient, the absolute value of the difference between actual and estimated weight (EPF difference = (Birth weight - Estimated weight) / Birth weight) was calculated. Among undetected macrosomic newborns (≥ 97th Audipog percentile), risk factors associated with misdiagnosis wer investigated (false negatives versus true positives).Résults : Ultrasound estimation of fetal weight at 36 SA to detect fetal macrosomia had a sensitivity of 43.7% and a specificity of 82.1%. With a positive predictive value for ultrasound of 36,9% and a negative predictive value of 85.8%. The mean absolute value of the difference between estimated and actual birth weight was 287g (95% CI [115-409]), with a mean relative difference of 6.8% (95% CI [3.0-11.3]). A relative difference of less than 10% between the estimated weight and the birth weight was found in 68.5% of the patients. Among macrosomic newborns (≥ 97th percentile), a third-trimester estimated fetal weight at or above the 90th percentile, along with a history of fetal macrosomia in a previous pregnancy, reduced the risk of false negatives in the screening ultrasound at 36 weeks of gestation.Conclusion : Ultrasound performed at 36 weeks' gestation in a population targeted for suspected fetal macrosomia in routine practice has moderate sensitivity and positive predictive value. It would be timely for teams also applying this protocol to share their results, in order to verify whether or not our findings can be generalized to a larger scale.

Heart rate response and recovery in cycle exercise testing - normal values and association with mortality.

Chronotropic incompetence and impaired heart rate (HR) recovery are related to mortality. Guidelines lack specific reference values for HR recovery. We defined normal values and studied blunted HR response and recovery, and mortality risk. We included 9,917 subjects (45% females) aged 18-85 years who performed a cycle exercise test. We defined normal values for peak HR, HR reserve, and HR recovery at 1 and 2 minutes (HRR1 and HRR2) based on individuals apparently healthy (N=2,242). Associations between blunted HR indices (<5th percentile) and mortality over a median follow-up of 8.6 years were analysed using Cox regression and competing risk analysis. All HR indices were age-dependent and independent predictors of all-cause and CV mortality. The 5th percentiles of HR reserve, HRR1, and HRR2 correlated weakly with existing reference values. HR recovery variables were the strongest predictors of all-cause mortality (HRR1, hazard ratio 1.70 [95% confidence interval, 1.49-1.94] and HRR2, 1.57 [1.37-1.79]), including in subjects with normal exercise capacity (HRR1, 1.96 [1.61-2.39] and HRR2, 1.76 [1.46-2.12]). Combining HR indices appeared to increase the risk of all-cause (HRR1 and HRR2, 1.96 [1.68-2.29] and peak HR and HRR1, 1.87 [1.56-2.23]) and CV mortality, although no specific combination was superior for predicting CV mortality. All HR variables were age-dependent and associated with all-cause and CV mortality. Blunted HR recovery variables were the strongest predictors of all-cause mortality, even in subjects with normal exercise capacity. Combined blunted HR indices appeared to add prognostic value.

High inpatient-opioid consumption predicts extended length of hospital stay in patients undergoing spinal fusion for adolescent idiopathic scoliosis.

Opioids are common medications used following spine surgery. However, few studies have assessed the impact of increased inpatient-opioid consumption on outcomes following posterior spinal fusion (PSF) for adolescent idiopathic scoliosis (AIS). The aim of this study was to determine the impact of increased inpatient-opioid consumption on hospital length of stay (LOS) following PSF for AIS. A retrospective cohort study was performed using the Premier Healthcare Database (2016-2017). Adolescent patients (11-17years old) who underwent PSF for AIS, identified using ICD-10-CM coding, were stratified by inpatient MME (morphine milligram equivalent) consumption into Low (< 25th percentile for the cohort), Medium (25-75th percentile), and High (> 75th percentile) cohorts. Demographics, comorbidities, intraoperative procedures, perioperative adverse events (AEs), length of hospital stay (LOS), non-routine discharge rates, cost of admission, and 30-day readmission rates were assessed. A logistic multivariate regression analysis was performed to determine the association between inpatient MME consumption and extended LOS. Of the 1042 study patients, 260 (24.9%) had Low-MME consumption, 523 (50.2%) had Medium-MME consumption, and 259 (24.9%) had High-MME consumption. A greater proportion of patients in the High cohort identified as non-Hispanic white (Low: 46.5% vs Medium: 61.4% vs High: 65.3%, p < 0.001), while the proportion of patients reporting any comorbidity did not vary across the cohorts (p = 0.940). The number of post-operative AEs experienced also did not vary across the cohorts (p = 0.629). A greater proportion of patients in the High cohort had an extended LOS (Low: 6.5% vs Medium: 8.6% vs High: 19.7%, p < 0.001), while a greater proportion of patients in the Low cohort had an increased cost of admission (Low: 33.1% vs Medium: 20.3% vs High: 26.6%, p < 0.001). The High cohort had increased 30-day readmission rates relative to the Low and Medium cohorts (Low: 0.8% vs Medium: 0.2% vs High: 1.5%, p = 0.049). Non-routine discharge rates did not vary among the cohorts (p = 0.441). On multivariate analysis, High-MME consumption was significantly associated with extended LOS, while Medium-MME consumption was not [Medium: aOR: 1.48, CI (0.83, 2.74), p = 0.193; High: aOR: 4.43, CI (2.47, 8.31), p < 0.001]. Our study showed that high post-operative-MME consumption was significantly associated with extended LOS in patients undergoing PSF for AIS. In light of these findings, changes to existing protocols that decrease the reliance on opioids for post-operative analgesia are merited to improve patient outcomes and reduce health-care expenditures.

Risks associated with prolonged latent phase of labor.

We sought to assess the impact of a prolonged latent phase (PLP) on maternal and neonatal morbidity. This is a secondary analysis of a prospective cohort study conducted 2010-2015 that included all term gravidas who reached active labor (six centimeters). Primary outcomes were composite maternal morbidity (maternal fever, postpartum hemorrhage, transfusion, endometritis, and severe perineal lacerations) and composite neonatal morbidity (respiratory distress syndrome, mechanical ventilation, birth injury, seizures, hypoxic ischemic encephalopathy, therapeutic hypothermia, or umbilical artery pH < 7.1). Outcomes were compared between patients with and without PLP, defined as > 90th percentile of labor duration between admission and active phase. Results were stratified by induction (IOL) vs. spontaneous labor. A stratified analysis was performed by mode of delivery. Multivariable logistic regression was used to adjust for confounders. In this cohort of 6509 patients, 51% underwent induction of labor. 650 patients had a PLP with a median length of 8.5 hours in spontaneous labor and 18.8 hours in IOL. Among patients with PLP, there was a significant increase in composite maternal morbidity with both IOL (aOR 1.36, 95% CI 1.01, 1.84) and spontaneous labor (aOR 1.49, 95% CI 1.09, 2.04) and an increase in composite neonatal morbidity with spontaneous labor only (aOR 1.57, 95% CI 1.01, 2.45). Cesarean delivery occurred more often in PLP group (14.0% versus 25.1%). Among patients who underwent cesarean delivery, PLP remained associated with increased odds of maternal morbidity compared to those with normal latent phase. PLP at or above the 90th percentile in patients who reach active labor is associated with increased risk of maternal morbidity that is not mediated by cesarean delivery. PLP in spontaneous labor is associated with increased neonatal morbidity. These data suggest that further research is needed to establish latent phase cut-offs that may be incorporated into labor management guidelines.

Navigating the Global Pandemic in Pediatric Overweight and Obesity: Emerging Challenges and Proposed Solutions.

Since 1990, childhood overweight and obesity have been rising on every continent and have almost doubled worldwide. The deleterious consequences include hypertension, type 2 diabetes mellitus, and dyslipidemia leading to metabolic syndrome in childhood and myocardial infarction, stroke, cancer and other disabling conditions in adulthood. In Southern Europe, including Greece, Italy, and Spain, 10 to 15% of children are obese. Obesity in Eastern European countries is somewhat lower, but the rates of rise are very steep and will approach those in Southern Europe during the next few years. Worldwide, Asia accounts for nearly half of all overweight children under the age of 5, while Africa is home to one quarter of overweight children under 5. In Latin America, about 20% of children under 20 are overweight. Further, children living in poverty can suffer simultaneous overweight and obesity as well as malnutrition. In the US, the risk of being overweight in adolescence is several times higher when a younger child has a body mass index (BMI) in the 50th or greater percentile. If the clinical, non-clinical and public health communities ignore these challenges, such inaction will surely portend an unprecedented future pandemic of overweight and obesity in children and adolescents leading to future premature morbidity and mortality. All clinical, non-clinical and public health professionals should exert concerted efforts concerning their individual patients, their families, communities, and policymakers. Such coordinated interdisciplinary efforts may curb these alarming trends and secure healthier futures for children and their families throughout the world.