Characterization of adult obesity in Florida using the OneFlorida clinical research consortium.

INTRODUCTION: With obesity rates and obesity-related healthcare costs increasing, policy makers must understand the scope of obesity across populations. OBJECTIVE: This study sought to characterize adult obesity using electronic health records (EHRs) available from a statewide clinical data research network, the OneFlorida Clinical Research Consortium, which contains claims and EHR data from over 12 million patients in Florida. The primary aim was to compare EHR-based Florida obesity rates with those rates obtained from the Behavioural Risk Factor Surveillance System (BRFSS). METHODS: Body mass index from OneFlorida patient data (2012-2016) was used to characterize obesity among adults 20-79 years old. Obesity rates from both OneFlorida and BRFSS (2013) were reported by demographics and by county. RESULTS: Among the 1,344,015 adults in OneFlorida with EHR data and who met inclusion criteria, the obesity rate was 37.1%. Women had higher obesity rates compared with men. Obesity rates varied within racial/ethnic groups, with the highest rate among African-Americans (45.7%). Obesity rates from OneFlorida were consistently higher than those found in BRFSS (overall 27.8%). CONCLUSIONS: Utilizing clinical big data available through hospital system and health partner collaborations provides an important view of the extent of obesity. Although these data are available only from healthcare users, they are large in scope, directly measured and are available sooner than commonly used national data sources.

The effects of experimentally manipulated social status on acute eating behavior: A randomized, crossover pilot study.

Both subjective and objectively measured social status has been associated with multiple health outcomes, including weight status, but the mechanism for this relationship remains unclear. Experimental studies may help identify the causal mechanisms underlying low social standing as a pathway for obesity. Our objective was to investigate the effects of experimentally manipulated social status on ad libitum acute dietary intakes and stress-related outcomes as potential mechanisms relating social status and weight. This was a pilot feasibility, randomized, crossover study in Hispanic young adults (n=9; age 19-25; 67% female; BMI ≥18.5 and ≤30kg/m(2)). At visit 1, participants consumed a standardized breakfast and were randomized to a high social status position (HIGH) or low social status position (LOW) in a rigged game of Monopoly™. The rules for the game differed substantially in terms of degree of 'privilege' depending on randomization to HIGH or LOW. Following Monopoly™, participants were given an ad libitum buffet meal and energy intakes (kcal) were estimated by pre- and post-weighing foods consumed. Stress-related markers were measured at baseline, after the game of Monopoly™, and after lunch. Visit 2 used the same standardized protocol; however, participants were exposed to the opposite social status condition. When compared to HIGH, participants in LOW consumed 130 more calories (p=0.07) and a significantly higher proportion of their daily calorie needs in the ad libitum buffet meal (39% in LOW versus 31% in HIGH; p=0.04). In LOW, participants reported decreased feelings of pride and powerfulness following Monopoly™ (p=0.05) and after their lunch meal (p=0.08). Relative to HIGH, participants in LOW demonstrated higher heart rates following Monopoly™ (p=0.06), but this relationship was not significant once lunch was consumed (p=0.31). Our pilot data suggest a possible causal relationship between experimentally manipulated low social status and increased acute energy intakes in Hispanic young adults, potentially influenced by decreased feelings of pride and powerfulness. Increased energy intake over time, resulting in positive energy balance, could contribute to increased risk for obesity, which could partially explain the observed relationship between low social standing and higher weight. Larger and longitudinal studies in a diverse sample need to be conducted to confirm findings, increase generalizability, and assess whether this relationship persists over time.

The relationship between mother to child calories served and maternal perception of hunger.

BACKGROUND: Research has examined self-serving portions in adults and children and has shown that larger portion size is related to more calories consumed. The present study examines factors that may influence the portion sizes a mother serves her child at a mealtime. METHODS: The present observational study included a community-based sample of 29 mother-child dyads. Dyads attended a 1-h session in which they shared a meal together. A buffet of food was provided and the mother was asked to serve her child and herself. The amount of food served and consumed by the child was recorded. Main independent variables of interest included maternal body mass index (BMI), child BMI Z-score, and maternal perception of personal and child hunger. The primary dependent variable was the total calories the mother served her child. Regression models and a moderated mediation were used to examine the relation between variables. RESULTS: Calories served to the child was positively associated with calories consumed by the child. Maternal perception of her own hunger was related to her perception of her child's hunger. Furthermore, maternal perception of child hunger explained the relationship between maternal perception of personal hunger and total calories served to the child, although only for obese mothers. CONCLUSIONS: Mothers may be serving their children larger portion sizes based on their personal weight and their perception of their child's hunger. To help children obtain or maintain a healthy weight, obesity prevention and intervention programmes should help mothers serve more appropriate serving sizes to their children.

Children's health care use: a prospective investigation of factors related to care-seeking.

OBJECTIVES: To determine the best predictors of the amount of children's health care use. RESEARCH DESIGN: Child health, psychosocial, and family status variables were collected. Families were then followed prospectively for 2 years to gather health care use data. Multivariate regression analysis was used to determine factors related to volume of child health care use. SUBJECTS: 367 mothers and children ages 5 to 11 years continuously enrolled in a staff model HMO. MEASURES: Child health care visits obtained from a computerized database comprised the dependent variable. Independent variables were organized into a 5-component framework including: Demographic Characteristics; Family Characteristics; Child Health and Prior Health Care Use; Child Behavior and Mental Health; and Mothers' Mental Health and Health Care Use. RESULTS: The volume of a child's past health care use was the best predictor of future health care use, with the presence of past acute recurring illnesses, child pain and mother's retrospective health care use also serving as significant predictors in the model. Analysis of a second model was conducted omitting children's past use of health care. In this model the mother's worry about child health was the best predictor of use, with child health and child and maternal psychosocial variables significantly contributing to explained variance in the model. CONCLUSIONS: This study supports prior research indicating past use is the best predictor of future health care use. In addition, the study suggests that maternal perceptions of child health and maternal emotional functioning influence the decision-making process involved in seeking health care on behalf of children. Effective management of pediatric health care use needs to address broader needs of the child and family beyond solely the child's health, most notably maternal functioning.

Medical communication: do our patients understand?

The objective of this study was to determine emergency department (ED) patient's understanding of common medical terms used by health care providers (HCP). Consecutive patients over 18 years of age having nonurgent conditions were recruited from the EDs of an urban and a suburban hospital between the hours of 7 a.m. and 11 p.m. Patients were asked whether six pairs of terms had the same or different meaning and scored on the number of correct answers (maximum score 6). Multiple linear regression analysis was used to assess possible relationships between test scores and age, sex, hospital site, highest education level, and predicted household income (determined from zip code). Two hundred forty-nine patients (130 men/119 women) ranging in age from 18 to 87 years old (mean = 39.4, SD = 14.9) were enrolled on the study. The mean number of correct responses was 2.8 (SD = 1.2). The percentage of patients that did not recognize analogous terms was 79% for bleeding versus hemorrhage, 78% for broken versus fractured bone, 74% for heart attack versus myocardial infarction, and 38% for stitches versus sutures. The percentage that did not recognize nonanalogous terms was 37% for diarrhea versus loose stools, and 10% for cast versus splint. Regression analysis (R2 = .13) revealed a significant positive independent relationship between test score and age (P < .024), education (P < .001), and suburban hospital site (P < .004). Predicted income had a significant relationship with test score (P < .001); however, this was no longer significant when controlled for the confounding influence of age, education and hospital site. Medical terminology is often poorly understood, especially by young, urban, poorly educated patients. Emergency health care providers should remember that even commonly used medical terminology should be carefully explained to their patients.

Predictors of unintentional injuries to school-age children seen in pediatric primary care.

OBJECTIVE: To identify predictors of unintentional injury to school-age children seen in pediatric primary care. METHODS: Members of a managed health care system (295 children ages 5-11 years and their mothers) participated. We used Time 1 measures of child, maternal, and family functioning and health care utilization to predict rates of unintentional child injury for the following year. Multiple regression analyses were performed to identify variables contributing to prospective injury rates. RESULTS: The final regression model included eight Time 1 variables and accounted for 21% of the variance in Time 2 injury rates. Significant predictors of increased injury liability were younger child age, more children at home, child behavior problems, child social competence, three indices of reduced child health, and maternal anxiety. CONCLUSIONS: We discuss the utility of these predictors for pediatric psychologists in targeting primary care preventive interventions to families at risk for unintentional child injury.

Empirically supported treatments in pediatric psychology: recurrent abdominal pain.

OBJECTIVE: To review the status of empirically supported treatments for recurrent abdominal pain (RAP). METHODS: We identified studies based on literature search and contact with experts in the field and evaluated studies based on guidelines modified from the criteria established by the Task Force on Promotion and Dissemination of Psychological Procedures. RESULTS: Nine published intervention studies were identified that fell into three distinctive approaches: operant procedures, fiber treatments, and cognitive-behavioral treatments. CONCLUSIONS: Operant procedures did not meet even the most lenient category (promising intervention) of the guidelines. Fiber treatment for RAP associated with constipation met the criteria for a promising intervention. Cognitive-behavioral treatment met the criteria for a probably efficacious intervention. We discuss implications and offer recommendations for future intervention research.

Anorectal disorders.

Anorectal disorders are commonly encountered in the practice of emergency medicine. Most can be diagnosed and treated in the emergency department setting. Almost all anorectal disorders once diagnosed and treated in the emergency department need appropriate follow-up to ensure adequacy of treatment, for further possible diagnostic procedures (e.g., endoscopy, biopsy), or for definitive treatment. Hemorrhoids are the most prevalent anorectal disorder and are the most common cause of hematochezia. Treatment is dependent on the degree of hemorrhoid prolapse and symptoms. Most cases can be treated by conservative medical treatment (e.g., dietary changes, sitz baths) or nonsurgical procedures (e.g., rubber band liagation, infrared coagulation). Surgical excision of symptomatic thrombosed external hemorrhoids is indicated if within 48 to 72 hours of pain onset. Anal fissures are one of the most common causes of anorectal pain. They are most frequently idiopathic, and most are located in the posterior midline of the anal canal. Most anal fissures are adequately treated by a medical approach using sitz baths, stool softeners, and analgesics. If the anal fissure becomes chronic and is not responsive to medical therapy, a lateral sphincterotomy of the internal anal sphincter is the surgical procedure of choice. Pharmacologic treatment (botulinum toxin or nitroglycerin ointment) to decrease internal anal sphincter tone has shown promise in the treatment of anal fissure. Anorectal abscesses are categorized into four types: perianal, ischiorectal, intersphincteric, and supralevator. Most are idiopathic and contain mixed aerobic-anaerobic pathogens. Fistula formation varies from 25% to 50% and is much more common with gut-derived organisms (e.g., E. coli, B. fragilis). Definitive treatment for an anorectal abscess is timely surgical incision and drainage to prevent more serious complications (e.g., serious infection, extension of the abscess). Anal carcinomas are infrequent, the majority of them being squamous cell or epidermoid carcinomas. The emergency physician must maintain a high index of suspicion and obtain a biopsy of suspicious lesions in order not to miss the diagnosis of a cancer. The most common presenting complaint of anal tumors is rectal bleeding. Combination chemotherapy and radiotherapy have shown promising results in the treatment of anal canal tumors. Bacterial, viral, and protozoal infections can be transmitted to the anorectum via anoreceptive intercourse. Such infections must be considered when a patient presents with rectal pain or discharge, tenesmus, or rectal or perineal ulcers. Proctosigmoidoscopy and rectal cultures may be necessary to determine the cause. Potential rectal complications of HIV infection include infectious diarrhea, acyclovir-resistant strains of HSV2, Kaposi's sarcoma, lymphoma, and squamous cell carcinoma. Rectal injuries may result from penetrating or blunt trauma, iatrogenic injuries, or foreign bodies. Rectal injury should be suspected when a patient presents with low abdominal, pelvic, or perineal pain or blood per rectum after sustaining trauma or undergoing an endoscopic or surgical procedure. Tetanus prophylaxis, intravenous antibiotics, and surgical intervention are indicated in all but superficial rectal tears.

Alcohol-related injuries among adolescents in the emergency department.

STUDY OBJECTIVE: To determine the frequency of positive alcohol readings in adolescent patients presenting for treatment of injury. DESIGN: Patients aged 10 through 21 years were prospectively enrolled in this descriptive study. Demographic data and information about the injury were collected at enrollment. Blood ethanol concentration was measured with a saliva alcohol assay with a lower detection limit of 10 mg/dL (2 mmol/L). SETTING: Enrollment was conducted at four emergency departments, an urban trauma center, an urban children's trauma center, a suburban hospital, and a rural hospital. Enrollment at each facility was conducted during two 24-hour periods for every day of the week (14 days total). Consecutive sampling was used during each enrollment period. RESULTS: We enrolled 295 patients (92% of eligible subjects). Sixty-three percent were male; 74% were white, 19% black, 3% Hispanic, 1% Asian, and 3% from other racial groups. The mean age was 15.6 +/- 3.2 years. Fifteen patients (5%) tested positive for ethanol (range, 10 to 120 mg/dL [2 to 24 mmol/L]). Only four of these patients underwent ethanol testing as part of their medical evaluations. Of the 125 subjects aged 17 through 21 years, 14 (11.2%) tested positive for ethanol. Hospital distribution was (number of patients with positive ethanol test results): urban trauma center, 8 of 52; urban children's trauma center, 0 of 91; suburban hospital, 4 of 111; rural hospital, 3 of 41. The highest percentage of positive ethanol test results was found at the urban trauma center, where 15% of total subjects and 22% of subjects aged 17 through 21 tested positive. Injuries related to assaults and motor vehicle crashes were particularly associated with alcohol use. CONCLUSION: Alcohol is associated with injuries in urban, suburban, and rural settings in the older pediatric population. Alcohol use is underrecognized and should be considered in patients presenting with injuries, especially victims of assaults or motor vehicle crashes.

Emergency medical care in the athletes' village: World University Games 1993.

OBJECTIVE: Little information exists concerning special medical needs at the athletes' residence (as distinct from the sport venues) at major international sporting events. During the summer of 1993, Buffalo, New York became the first city in the United States to host the World University Games. Approximately 6,000 athletes and accompanying staff from 118 countries attended. This report seeks to characterize emergency medical care use and the degree of language difficulty encountered at the athletes' village medical center (AVMC) set up at the athletes' residence for this event. METHODS: Demographic data were collected prospectively for each athlete or staff member housed in the athletes' village who presented to AVMC for medical evaluation rather than being cared for by a team physician or at one of the venues. Difficulty in medical treatment secondary to language differences was assessed by the treating physician on a scale of 0-3. RESULTS: Over the 14 days that the AVMC was in operation, for 24 hours a day, a total of 362 athletes (mean age: 22.9 +/- 2.9 years, 257 males, 105 females) and 149 accompanying staff (mean age: 39.8 +/- 11.6 years, 110 males, 39 females) were treated. More than 90% of the patients were seen between the hours of 0800 and 2400. A broad spectrum of minor medical problems occurred, with musculoskeletal injuries accounting for most of the visits for both athletes (54%) and staff (27%). Nonsteroidal anti-inflammatory agents and oral antibiotics were the most commonly prescribed medications. On-site radiographic facilities were used for 22% of the athletes and 11% of the staff treated. The majority of patients (92% of athletes, 91% of staff) were discharged from the AVMC. Four of the 12 patients that were transferred to a hospital-based emergency department were admitted to the hospital. Language problems, as assessed by the treating physician, were mostly minor; 25% of the patients had accompanying interpreters. One volunteer physician, and two to three nurses adequately staffed each shift. CONCLUSION: The AVMC provided medical care for a large variety of medical problems that could be treated on-site without transfer to a higher-level facility, thereby providing directed medical care for this special population in a secure environment. Language differences were perceived as a minor problem. This report should be valuable in the planning of medical care at the athletes' residences for similarly large sporting events.

Pharmacokinetics of two multiple-dose mezlocillin regimens.

The pharmacokinetics of mezlocillin at two dosages were studied over the course of therapy in 12 patients receiving the drug for the treatment of infections. Patients received an initial dosing regimen of 4 g every 6 h or 5 g every 8 h, which was switched to the alternative regimen after 5 days of treatment. Both drug regimens demonstrated similar pharmacokinetic characteristics, which suggests that the reported dose-dependent elimination of mezlocillin is not an important factor in the clinical use of mezlocillin at the dosages currently used.

Developmental pharmacokinetics of mezlocillin in 4 newborn infants.

The disposition of mezlocillin was evaluated in 4 newborn infants in a sequential two-phase study at postnatal ages of 1 day and 8 or 10 days. Renal function was estimated by creatinine clearance (CLCR) and pharmacokinetic parameters of mezlocillin was were determined from serum concentrations and urinary excretion rates. All weight-normalized mezlocillin clearances (total, renal, and nonrenal) and CLCR were less than adult values, but increased after 8 or 10 days of mezlocillin therapy and postnatal development. The volume of distribution at steady state did not significantly change throughout this period, and approximated the expanded extracellular fluid volume typically found in neonates. The elimination half-lives were substantially shorter by phase II of the study. Both renal and nonrenal elimination processes were enhanced by 1 week of postnatal development even though body weight did not increase. Mezlocillin disposition in neonates is thus affected by body weight, gestational age, and postnatal age.

Pharmacokinetic modeling of bidirectional transfer during peritoneal dialysis.

A pharmacokinetic model and distributional clearance terms to describe bidirectional peritoneal transfer were used to examine cefamandole pharmacokinetics in five uninfected patients with end-stage renal disease who were receiving continuous ambulatory peritoneal dialysis. Each patient received intravenous and intraperitoneal 1 gm doses of drug, and serum and dialysate samples were collected over three dialysis dwell periods. The mean systemic availability of cefamandole after intraperitoneal dosing was 0.71 +/- 0.1. No significant differences in the serum-to-peritoneal fluid and peritoneal fluid-to-serum distributional clearances were observed. The time dependence of peritoneal dialysis clearance was examined. The amount of drug found in the dialysate divided by the corresponding serum AUC was empirically found to estimate the time-averaged peritoneal dialysis clearance. A mass balance-area method to calculate distributional clearance was developed that obviates more complicated computer fitting of the data. We present a comprehensive modeling approach that should be useful in the examination of the kinetics of drugs during continuous ambulatory peritoneal dialysis.

Pharmacokinetics of aztreonam in patients with gram-negative infections.

Aztreonam pharmacokinetics were assessed in seven patients treated for urinary (n = 6) or lower respiratory (n = 1) tract infections. Each patient was studied twice, at the beginning and end of therapy (7 to 10 days). The patients enrolled had normal to moderately impaired renal function; a good correlation (r2 = 0.90) between serum aztreonam clearance (CL) and creatinine clearance (CLCR) was observed (mean CL/CLCR ratio = 1.11). CL ranged from 21.6 to 121 ml/min per 70 kg, and the half-life ranged from 1.6 to 8.9 h. The mean steady-state volume of distribution (0.16 +/- 0.05 [standard deviation] liter/kg) approximated the extracellular fluid volume. Protein binding of aztreonam in serum (mean, 30%) was lower than that reported in healthy adults. CL increased significantly from the first to the last day of the study, probably reflecting increasing renal function. After multiple dosing (1 g every 8 h), no significant accumulation of aztreonam was observed. Overall, the disposition of aztreonam is comparable in infected and noninfected subjects, and dosing adjustments in patients with renal impairment should be facilitated by the good correlation between CL and CLCR.

Developmental pharmacokinetics of mezlocillin in newborn infants.

Single-dose pharmacokinetics of mezlocillin were studied in 53 newborn infants (72% less than or equal to 36 weeks' gestation) given ampicillin and an aminoglycoside for suspected or proved sepsis. Mezlocillin (75 mg/kg IV or IM) was substituted for ampicillin, serum was assayed microbiologically, and noncompartmental pharmacokinetic parameters were calculated. Analysis of covariance showed that dose/area under the serum concentration-time curve for mezlocillin was influenced by body weight, intramuscular administration, and treatment with gentamicin. A dual intravenous/intramuscular nonlinear regression model yielded an apparent intramuscular bioavailability of 84%. Clearance was proportional to body weight (WT) (r2 = 0.70). Mean CL/WT (0.078 L/hr/kg) was one-half adult values and influenced by gestational age. Steady-state volume of distribution varied linearly with weight (r2 = 0.80), the mean value (0.38 L/kg) being twice that in adults. Mezlocillin half-life (mean 3.71 hours) exceeded adult values and did not correlate with weight. Twenty-four newborn infants received 75 mg/kg mezlocillin every 6 or every 8 hours, along with gentamicin, during the first 7 to 10 days of life. Peak (1.5 hours) and trough (6 or 8 hours) concentrations were determined; the latter decreased from day 3 to days 7 to 10, suggesting a possible postnatal age-dependent change in mezlocillin elimination. Although mezlocillin disposition is affected by age and therapeutic factors, weight alone may adequately predict dosing requirements.

Mezlocillin disposition in chronic hemodialysis patients.

The pharmacokinetics of a single 1-g intravenous dose of mezlocillin were examined in six functionally anephric patients undergoing hemodialysis. Hemodialysis clearance calculated by plasma extraction ratios across the dialyzer membrane and by dialysis fluid agree well, averaging 26 and 32 ml/min. Dialyzer extraction ratios averaged 0.16 +/- 0.07, and 23.3 +/- 9.6% of the dose was measured in the dialysate. Plasma clearances (104 +/- 45 ml/min) and steady-state volumes of distribution (0.22 +/- 0.07 liter/kg) of mezlocillin showed good agreement with literature values. The nonrenal clearance (4.25 +/- 2.30 liters/h per 1.73 m2) of mezlocillin was appreciable. Drug loss by hemodialysis is small and should have little effect on therapeutic dosage needs.

High-pressure liquid chromatography analysis and single-dose disposition of tobramycin in human volunteers.

A sensitive and specific fluorometric high-pressure liquid chromatography technique was developed to measure both tobramycin and an internal standard (gentamicin C2). The assay utilizes direct extraction of the o-phthalaldehyde derivatives from serum and urine. Coefficients of variation were 7.9% (serum) and 6.0% (urine) at a tobramycin concentration of 1.0 microgram/ml. The lower limit of assay sensitivity was 0.2 microgram/ml. Results obtained from high-pressure liquid chromatography were in excellent agreement with those from radioimmunoassay for both serum (r = 0.97) and urine (r = 0.91). No other aminoglycoside antibiotics and no other antibiotics that were tested caused interfering peaks. Tobramycin (1 mg/kg intravenous bolus) was administered to three healthy volunteers. Tobramycin concentrations were detectable for 10 h in serum and for 240 h in urine after a 1-mg/kg intravenous dose. A two-compartment pharmacokinetic model was required to describe the tobramycin disposition. Urinary recovery of tobramycin over a 10-day period accounted for 95.8, 94.3, and 83.1% of the administered dose. High-pressure liquid chromatography methodology is sufficiently sensitive to determine single-dose, two-compartment tobramycin pharmacokinetics from urinary excretion data, thus verifying the prolonged excretion of tobramycin after a single dose. The analytical methodology and pharmacokinetic techniques described may be useful in studying other aminoglycosides.