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Migraine is a common neurologic disorder in children and adolescents. However, a comparison of multiple nonpharmacological treatments is lacking.OBJECTIVE:
To examine whether nonpharmacological treatments are more effective than waiting list and whether there are differences between interventions regarding efficacy.DATA SOURCES:
Systematic review and network meta-analysis of studies in Medline, Cochrane, Embase, and PsycINFO published through August 5, 2019.STUDY SELECTION:
Randomized controlled trials of nonpharmacological treatments in children and adolescents diagnosed with episodic migraine.DATA EXTRACTION:
Effect sizes, calculated as standardized mean differences (SMDs) for the primary outcome efficacy, were assessed in a random-effects model.RESULTS:
Twelve studies (N = 576) were included. When interventions were classified into groups on the basis of similarity of treatment components, self-administered treatments, biofeedback, relaxation, psychological treatments, and psychological placebos were significantly more effective than waiting list with effect sizes ranging between SMD = 1.14 (95% confidence interval, 0.09 to 2.19) for long-term psychological placebos to SMD = 1.44 (95% confidence interval, 0.26 to 2.62) for short-term self-administered treatments. However, when all interventions were examined individually (ie, 1 node per intervention), none were significantly more effective compared with waiting list, mainly because of lack of statistical power.LIMITATIONS:
Because of our focus on pediatric migraine, only a small number of studies could be included.CONCLUSIONS:
Our findings reveal that components of nonpharmacological interventions are effective in treating pediatric migraine. Some effects have to be interpreted carefully because they are based on small studies. Future researchers should identify factors associated with individual responses in large, multicentered studies.
One in five pediatric patients suffers from adverse events related to hospital discharge. Current literature lacks evidence on effective interventions to improve caregiver comprehension (CC) of discharge instructions. We examined if a standardized framework for written and verbal discharge counseling was associated with increased CC of key discharge instructions after discharge from a general pediatric inpatient unit.METHODS:
An interprofessional team created the SAFER Care framework to encourage standard, comprehensive discharge counseling. Plan-do-study-act cycles included electronic health record smartphrases, educational initiatives, data feedback, visual aids, and family outreach. Caregivers were surveyed by phone within 4 days of discharge. Our primary outcome was the proportion of caregivers correctly responding to all questions related to discharge care, comparing pre- and postintervention periods. Data were plotted on a statistical process control chart to assess the effectiveness of interventions.RESULTS:
A total of 171 surveys were analyzed in the preintervention period, and 262 surveys were analyzed in the postintervention period. A total of 37% of caregivers correctly responded to all questions in the preintervention period, compared with 62% of caregivers in the postintervention period, meeting rules for special cause variation.CONCLUSIONS:
Development of the SAFER Care framework and its use in written and verbal discharge counseling was associated with significantly improved CC of discharge instructions in a general pediatric inpatient unit. Further studies should be focused on expanding this to other populations, particularly limited–English-proficiency families.
Pediatric ethics consultations are important but understudied, with little known about consultations’ contextual attributes, which may influence how ethically problematic situations are perceived and addressed.METHODS:
We analyzed data regarding 245 pediatric clinical ethics consultations performed between 2013 and 2018 at a large children’s hospital. Prespecified data elements included 17 core problematic issues that initiate consultations, 9 ethical considerations identified by the consultation service, and 7 relational, emotional, and pragmatic contextual attributes of the consultation. The main process measure was the cumulative consultation process, ranging from one-on-one discussions with the requestor, to meeting with the clinical team, separate meetings with the patient or family and the clinical team, or combined meeting with the patient or family and the clinical team.RESULTS:
The most-prevalent core problematic issues were intensity or limitation of treatment (38.8%) and treatment adherence and refusal (31%). Common pertinent ethical considerations were best interest (79.2%), benefits versus harms of treatment (51%), and autonomy and decision-making (46.5%). A total of 39.2% of consults culminated with a meeting with the clinical team, 9.4% with separate meetings, and 8.2% with a meeting with all parties. Common contextual attributes were discord (43.3%), acknowledged dilemma (33.5%), and articulate disagreement (29.8%). In exploratory analyses, specific contextual attributes were associated with the core problematic issue that initiated the consultation and with how the consultative process culminated.CONCLUSIONS:
Pediatric ethics consultations have contextual attributes that in exploratory analyses are associated with specific types of problems and, to a lesser degree, with the cumulative ethics consultation process.
Opioid overdose and abuse have reached epidemic rates in the United States. Medical prescriptions are a large source of opioid misuse. Our quality improvement initiative aimed to reduce opioid exposure from the pediatric emergency department (ED). Objective was to reduce opioid doses prescribed weekly from our ED by 50% within 4 months.METHODS:
Three categories of interventions were implemented in Plan-Do-Study-Act cycles: guidelines and education, electronic medical record optimization, and provider-specific feedback. Primary measures were opioid doses prescribed weekly from the ED and opioid doses per 100 ED visits. Process measures were opioid prescriptions, opioid doses per prescription, and opioid prescriptions for unspecified abdominal pain, headache, and viral upper respiratory infection. Balancing measures were phone calls and return visits for poor pain control in patients prescribed opioids and reports of poor pain control in call backs to orthopedic reduction patients. We used statistical process control to examine changes in measures over time.RESULTS:
Opioid doses decreased from 153 to 14 per week and from 8 to 0.7 doses per 100 ED visits in 10 months, sustained for 9 months. Opioid prescriptions, opioid doses per prescription, and prescriptions for unspecified abdominal pain, headache, and viral upper respiratory infection decreased. Phone calls and return visits in patients prescribed opioids did not increase. There were 2 reports of poor pain control among 152 orthopedic reduction patients called back.CONCLUSIONS:
We decreased opioid doses prescribed weekly from the pediatric ED by 91% while minimizing return visits and reports of poor pain control.
Severe intraventricular hemorrhage (IVH) is a leading mortality risk factor among extremely premature neonates. Because other life-threatening conditions also occur in this population, it is unclear whether severe IVH is independently associated with death. The existence and potential implications of regional variation in severe IVH–associated mortality are unknown.METHODS:
We performed a retrospective cohort study of mechanically ventilated neonates born at 22 to 29 weeks’ gestation who received care in 242 American NICUs between 2000 and 2014. After building groups composed of propensity score–matched and center-matched pairs, we used the Cox proportional hazards analysis to test our hypothesis that severe IVH would be associated with greater all-cause in-hospital mortality, defined as death before transfer or discharge. We also performed propensity score–matched subgroup analyses, comparing severe IVH–associated mortality among 4 geographic regions of the United States.RESULTS:
In our analysis cohort, we identified 4679 patients with severe IVH. Among 2848 matched pairs, those with severe IVH were more likely to die compared with those without severe IVH (hazard ratio 2.79; 95% confidence interval 2.49–3.11). Among 1527 matched pairs still hospitalized at 30 days, severe IVH was associated with greater risk of death (hazard ratio 2.03; 95% confidence interval 1.47–2.80). Mortality associated with severe IVH varied substantially between geographic regions.CONCLUSIONS:
The early diagnosis of severe IVH is independently associated with all-cause in-hospital mortality in extremely premature neonates. Regional variation in severe IVH–associated mortality suggests that shared decision-making between parents and neonatologists is strongly influenced by ultrasound-based IVH assessment and classification.
In Zambia, a significant number of infants die in the community. It is hypothesized that delays in care contribute to many of these so-called "brought in dead" infants.METHODS:
We analyzed free-text narratives from verbal autopsies, in which families narrate the final series of events leading to each infant’s death. Using the 3-delays model framework and working iteratively to achieve consensus, we coded each narrative using NVivo software to identify, characterize, and quantify the contribution of delays and other factors to the fatal outcome.RESULTS:
Verbal autopsies were collected from 230 families of brought in dead infants younger than 6 months of age. As many as 82.8% of infants had 1 or more delays in care. The most-common delay was in the family’s decision to seek care (54.8%), even as severe symptoms were frequently described. Similarly, 27.8% of infants died en route to a health care facility. Delays in receiving adequate care, including infants dying while waiting in line at a clinic or during referral from a clinic to a hospital, occurred in 24.7% of infants. A third of infants had been previously evaluated by a clinician in the days before their death.CONCLUSIONS:
Delays in care were the rule rather than the exception in this population of Zambian infants. Accessing care requires families to navigate significant logistic barriers, and balance complex forces in deciding to seek care. Strategies to avoid such delays could save many infants lives.
Antenatal consultation between a neonatologist and expectant parent(s) may determine if resuscitation is provided for or withheld from neonates born in the gray zone of viability. In this study, we sought to gain a deeper understanding of uncertainties present and neonatologists’ communication strategies regarding such uncertainties in this shared decision-making.METHODS:
A prospective, qualitative study using transcriptions of audio-recorded antenatal consultations between a neonatologist and expectant parent(s) was conducted. Pregnant women were eligible if anticipating delivery in the gray zone of viability (22 0/7–24 6/7 weeks’ gestation). Over 18 months, 25 of 28 pregnant women approached consented to participate. Applied thematic analysis was used to inductively derive and examine conceptual themes.RESULTS:
Inductive analysis of consult transcripts revealed uncertainty as a central theme. Several subthemes relating to uncertainty were also derived, including the timing of delivery, NICU course, individual characteristics (of physician, expectant parent(s), and fetus or neonate), and consequences of the decision for the expectant parent(s). Analysis revealed that uncertainty was actively managed by neonatologists through a variety of strategies, including providing more information, acknowledging the limits of medicine, acknowledging and accepting uncertainty, holding hope, and relationship building.CONCLUSIONS:
Uncertainty is pervasive within the antenatal consultation for periviable neonates and likely plays a significant role in decision-making toward postnatal resuscitative efforts. Uncertainty complicated, or even paralyzed, decision-making efforts while also providing reassurance toward a positive outcome. Directions for future study should consider whether advanced communication training modulates the impact that uncertainty plays in the shared decision-making encounter.
The objective of this study was to describe the outcomes of implementing a high-risk bruise screening pathway in a pediatric emergency department (ED).METHODS:
A retrospective observational study was performed of children aged 0 to <48 months who presented to the ED between December 1, 2016, and April 1, 2019, and had bruising that is high-risk for physical abuse on a nurse screening examination. A high-risk bruise was defined as any bruise if aged <6 months or a bruise to the torso, ears, or neck if aged 6 to <48 months. Records of children with provider-confirmed high-risk bruising were reviewed.RESULTS:
Of the 49 726 age-eligible children presenting to the ED, 43 771 (88%) were screened for bruising. Seven hundred eighty-three (1.8%) of those children had positive screen results and 163 (0.4%) had provider-confirmed high-risk bruising. Of the 8635 infants aged <6 months who were screened, 48 (0.6%) had high-risk bruising and 24 of 48 (50%) were classified as cases of likely or definite abuse. Skeletal surveys were performed in 29 of 48 (60%) infants, and 11 of 29 (38%) had occult fracture. Of the 35 136 children aged 6 to <48 months who were screened, 115 of 35 136 (0.3%) had high-risk bruising and 32 of 115 (28%) were classified as cases of likely or definite abuse.CONCLUSIONS:
High-risk bruising was rarely present. When infants aged <6 months were evaluated per recommendations, occult fracture was identified in one-third of patients. The screening pathway could help other institutions identify occult injuries in pediatric ED patients.
Transgender adolescents experience disproportionately high rates of dating violence and peer victimization. However, research has relied on small samples of transgender youth and has not captured victimization experiences of gender-expansive youth (who do not identify as male, female, or transgender). In the current study, we address these limitations, comparing victimization by gender.METHODS:
We examined a subsample of 4464 male, female, transgender, and gender-expansive youth (1116 per group) from the 2018 Illinois Youth Survey who were frequency matched on grade, race, geographic region, and free or reduced lunch status. Prevalence of self-reported verbal, physical, and cyber peer victimization and physical and psychological dating violence was calculated. Adjusted prevalence ratios were obtained by using log-binomial regression.RESULTS:
The highest rates across all forms of victimization were reported among transgender (15.6%–51.6%) and gender-expansive (13.2%–41.4%) youth. Transgender youth had a 2.09 to 2.96 times higher frequency of victimization than male youth and a 1.34 to 2.65 times higher frequency of victimization than female youth. Transgender youth also had higher frequencies of specific forms of victimization than gender-expansive youth. Gender-expansive youth had a 1.83 to 2.61 times higher frequency of victimization than male youth and 1.18 to 2.35 times higher frequencies of most forms of victimization than female youth.CONCLUSIONS:
Disparities in dating violence and peer victimization rates exist among transgender and gender-expansive adolescents compared with male and female youth. The distinct experiences of transgender and gender-expansive youth should be considered in school policies and violence prevention programs.
Umbilical cord nonseverance (UCNS) is the practice of leaving the umbilical cord attached to the placenta after delivery. Limited case reports exist revealing adverse outcomes of UCNS. We report a case of neonatal omphalitis associated with Escherichia coli bacteremia and urinary tract infection after UCNS.
Since the 2016 Zika outbreak and the understanding of the teratogenic effect of this infection, there has been a newfound interest in arbovirus infections and their effects on pregnancy, resulting in numerous publications in the last 5 years. However, limited literature focuses on arbovirus infection in different stages of pregnancy and their effect on the neonate. There is currently no consensus management of perinatal acquisition of arboviruses, and current evidence is largely anecdotal observational reports. Teratogens can have different effects on the developing fetus depending on the time of infection, so infections during pregnancy should be analyzed by trimester. A better understanding of arbovirus infection in the perinatal period is required to assist obstetric, neonatal, and pediatric clinicians in making decisions about the management of mother and neonate. Our objective was to assess the evidence of adverse neonatal outcomes for several arboviral infections when contracted during the perinatal period to guide clinicians in managing these patients. There are 8 arboviruses for which neonatal outcomes from maternal acquisition in the perinatal period have been reported, with the most data for dengue and Chikungunya virus infections. The evidence reviewed in this article supports the adoption of preventive strategies to avoid ticks and mosquitoes close to the date of delivery. For the other arbovirus infections, further community-based cohort studies during outbreaks are required to evaluate whether these infections have a similar teratogenic impact.