Pain without known pathology, termed "functional pain," causes much school absenteeism, medication usage, and medical visits. Yet which adolescents are at risk is not well understood. Functional pain ...has been linked to childhood abuse, and sexual orientation minority youth (gay, lesbian, bisexual, "mostly heterosexual," and heterosexual with same-sex sexual contact) are more likely to be victims of childhood abuse than heterosexuals, thus may be at greater risk of functional pain.
We examined sexual orientation differences in past-year prevalence of functional headache, pelvic, and abdominal pain and multiple sites of pain in 9,864 young adults (mean age = 23 years) from a large U.S. cohort. We examined whether childhood abuse accounted for possible increased risk of functional pain in sexual minority youth.
Sexual minority youth, except for gays and lesbians, were at higher risk of functional pelvic and abdominal pain and multiple sites of pain than heterosexuals. Gay and lesbian youth had elevated prevalence only of abdominal pain. Childhood abuse accounted for 14% to 33% of increased experience of multiple sites of pain in minority youth.
Youth who identify as "mostly heterosexual" or bisexual or who identify as heterosexual and have had same-sex partners comprised 18% of our sample. Clinicians should be aware that patients with these orientations are at elevated risk of functional pain and may be in need of treatment for sequelae of childhood abuse. Conventional categorization of sexual orientation as heterosexual or homosexual may fail to distinguish a large number of youth who do not wholly identify with either group and may be at elevated risk of health problems.
Celotno besedilo
Dostopno za:
DOBA, IZUM, KILJ, NUK, PILJ, PNG, SAZU, SIK, UILJ, UKNU, UL, UM, UPUK
Few papers discuss the pragmatics of conducting large, cluster randomized clinical trials. Here we describe the sequential steps taken to develop methods to implement the Randomized Evaluation of ...Sedation Titration for Respiratory Failure (RESTORE) trial that tested the effect of a nurse-implemented, goal-directed, comfort algorithm on clinical outcomes in pediatric patients with acute respiratory failure.
After development in a single institution, the RESTORE intervention was pilot-tested in two pediatric intensive care units (PICUs) to evaluate safety and feasibility. After the pilot, the RESTORE intervention was simplified to enhance reproducibility across multiple PICUs. The final RESTORE trial was developed as a cluster randomized clinical trial where the unit of randomization was the PICU, stratified by PICU size, and the unit of inference was the patient. Study execution was revised based on our Data and Safety Monitoring Board's recommendation to consult with the Department of Health and Human Services' Office of Human Research Protection (OHRP) on how best to consent eligible subjects. OHRP deemed that the RESTORE intervention posed greater than minimal risk and that all enrolled subjects provide consent reflecting their level of participation.
Thirty-one PICUs of varying size, organization and academic affiliation participated and over 2800 critically ill infants and children supported on mechanical ventilation for acute pulmonary disease were enrolled. The primary outcome for the trial was the duration of mechanical ventilation; secondary outcomes included time awake and comfortable, total sedative exposure and iatrogenic withdrawal symptoms. Throughout the clinical trial the investigative team worked to maintain treatment fidelity, enrollment milestones and co-investigator enthusiasm. We considered the potential impact of competing clinical trials through a decision-making framework.
The RESTORE clinical trial was a large and complex multicenter study that has provided the necessary evidence to guide sedation practices in the field of pediatric critical care. Specific issues that were unique to this trial included level of consent, adding clinical sites to augment enrollment and evaluating the potential impact of competing clinical trials.
ClinicalTrials.gov , Identifiers: Pilot trial: NCT00142766 ; Retrospectively registerd on 2 September 2005. Cluster randomized trial: NCT00814099 . Registered on 23 December 2008.
Objective
Persons with congenital heart disease (CHD) are at increased risk of neurodevelopmental disabilities, including impairments to executive function. Sulcal pattern features correlate with ...executive function in adolescents with single‐ventricle heart disease and tetralogy of Fallot. However, the interaction of sulcal pattern features with genetic and participant factors in predicting executive dysfunction is unknown.
Methods
We studied sulcal pattern features, participant factors, and genetic risk for executive function impairment in a cohort with multiple CHD types using stepwise linear regression and machine learning.
Results
Genetic factors, including predicted damaging de novo or rare inherited variants in neurodevelopmental disabilities risk genes, apolipoprotein E genotype, and principal components of sulcal pattern features were associated with executive function measures after adjusting for age at testing, sex, mother's education, and biventricular versus single‐ventricle CHD in a linear regression model. Using regression trees and bootstrap validation, younger participant age and larger alterations in sulcal pattern features were consistently identified as important predictors of decreased cognitive flexibility with left hemisphere graph topology often selected as the most important predictor. Inclusion of both sulcal pattern and genetic factors improved model fit compared to either alone.
Interpretation
We conclude that sulcal measures remain important predictors of cognitive flexibility, and the model predicting executive outcomes is improved by inclusion of potential genetic sources of neurodevelopmental risk. If confirmed, measures of sulcal patterning may serve as early imaging biomarkers to identify those at heightened risk for future neurodevelopmental disabilities.
We examined changes in cerebral oxygen saturation during infant heart surgery and its relationship to anatomic diagnosis and early outcome.
Regional cerebral oxygen saturation (rSO(2)) was measured ...by near-infrared spectroscopy in 104 infants undergoing biventricular repair without aortic arch obstruction as part of a randomized trial of hemodilution to a hematocrit of 25% vs 35%.
Before cardiopulmonary bypass (CPB), infants with tetralogy of Fallot had higher rSO(2) values compared to those with D-transposition of the great arteries (D-TGA) or ventricular septal defect (P < 0.001). During CPB cooling, low flow, and at the termination of CPB, D-TGA subjects had the highest rSO(2) values (P < 0.001). There were no significant associations between intraoperative rSO(2) and early postoperative outcomes after adjustment for diagnosis. In 39 D-TGA subjects with > or =5 min of deep hypothermic circulatory arrest (DHCA), there was no correlation between the rSO(2) (91% +/- 6%) or hematocrit (29.2% +/- 5.5%) at the onset of arrest and the rate of decline in rSO(2) during arrest.
Intraoperative rSO(2) varies according to anatomic diagnosis but accounts for very little of the variance in early outcome. As measured by frontal near-infrared spectroscopy, higher levels of hematocrit and current perfusion techniques appear to provide an adequate oxygen reservoir prior to relatively short periods of DHCA.
Background
Systemic vasodilation using α‐receptor blockade has been shown to decrease the incidence of postoperative cardiac arrest following stage 1 palliation (S1P), primarily when utilizing the ...modified Blalock‐Taussig shunt. We studied the effects of a protocol in which milrinone was primarily used to lower systemic vascular resistance (SVR) following S1P using the right ventricular to pulmonary artery shunt, measuring its effects on oxygen delivery (DO2) profiles and clinical outcomes. We also correlated Fick‐based assessments of DO2 with commonly used surrogate measures.
Methods and Results
Neonates undergoing S1P were treated according to best clinical judgment prior to (n=32) and following (n=24) implementation of a protocol that guided operative, anesthetic, and postoperative management, particularly as it related to SVR. A majority of the subjects (n=51) received a modified right ventricular to pulmonary artery shunt. In a subset of these patients (n=21), oxygen consumption (VO2) was measured and used to calculate SVR, DO2, and oxygen debt. Neonates treated with the protocol had significantly lower SVR (P=0.02), serum lactate (P<0.001), and Sa‐vO2 difference (P<0.001) and a lower incidence of CPR requiring extracorporeal membrane oxygenation (E‐CPR, P=0.02) within the first 72 postoperative hours. DO2 was closely associated with SVR (r2=0.78) but correlated poorly with arterial (SaO2) and venous (SvO2) oxyhemoglobin concentrations, the Sa‐vO2 difference, and blood pressure.
Conclusions
A vasodilator protocol utilizing milrinone following S1P effectively decreased SVR, improved serum lactate, and decreased postoperative cardiac arrest. DO2 correlated more closely with SVR than with Sa‐vO2 difference, highlighting the importance of measuring VO2 in this population.
Clinical Trial Registration
URL: http://www.clinicaltrials.gov. Unique identifier: NCT02184169.
AbstractFollowing publication of the original article 1, the authors notified us of a typing error in spelling Dr. Asario's name. The original publication has been corrected.
Often, pediatric intensive care environments are not conducive to healing the sick. Critically ill children experience disruptions in their circadian rhythms, which can contribute to delayed recovery ...and poor outcomes. We aim to test the hypothesis that children managed via RESTORE Resilience (R2), a nurse-implemented chronotherapeutic bundle, will experience restorative circadian rhythms compared to children receiving usual care. In this two-phased, prospective cohort study, two separate pediatric intensive care units in the United Sates will enroll a total of 20 baseline subjects followed by 40 intervention subjects, 6 months to less than 18 years of age, requiring invasive mechanical ventilation. During the intervention phase, we will implement the R2 bundle, which includes: (1) a focused effort to replicate the child's pre-hospitalization daily routine, (2) cycled day-night lighting and sound modulation, (3) minimal yet effective sedation (RESTORE), (4) nighttime fasting with bolus enteral daytime feedings, (5) early progressive mobility (PICU Up!), (6) continuity in nursing care, and (7) parent diaries. Our primary outcome is circadian activity ratio post-extubation. We hypothesize that children receiving R2 will experience restored circadian rhythms as evidenced by decreased nighttime activity while in the PICU. Our exploratory outcomes include salivary melatonin levels; electroencephalogram (EEG) slow-wave activity; R2 feasibility, adherence, and system barriers; levels of patient comfort; exposure to sedative medications; time to physiological stability; and parent perception of being well cared for. This paper describes the design, rationale, and implementation of R2.
NCT04695392.
•Circadian dysrhythmias are common in critically ill children.•Nurse-led interprofessional teams are uniquely positioned to implement CR-restoring interventions in critically ill children.•A chronotherapeutic bundle may improve circadian dysrhythmias in critically ill children and improve patient outcomes.
To describe nurse decision making and patient responses associated with the administration of analgesics and sedatives in the pediatric cardiac ICU.
Prospective nonexperimental mixed methods study of ...pediatric cardiac ICU nursing practice.
Three tertiary academic pediatric heart centers in the United States.
Pediatric cardiac ICU nurses caring for 217 patients completed 1,330 surveys.
Four-item open-ended nurse survey completed each time an as needed dose of an analgesic or sedative was administered, an analgesic or sedative infusion/dose was titrated, and/or a new analgesic or sedative was administered.
Responses to survey questions were entered verbatim and then collapsed using a consensus process. Collapsing of the data continued until there was a working set of "symptoms," "changes," and "clinical situation managed" categories. Nurses identified 28 symptoms managed with analgesia and sedation. The most frequent symptoms included hypertension, tachycardia, crying, pain, and agitation. Nurses identified 20 patient changes that resulted from their interventions. The most prevalent changes included improved hemodynamics, calm state, sleep, comfort, and relaxed state. Nurses identified 22 clinical situations that they were attempting to manage. The most frequent clinical situations included pain, hemodynamics, procedures, hypertension, and agitation. Nurses responded that 22% of their interventions were influenced by others.
Pediatric cardiac ICU nurses use many nonspecific indicators to describe patient level of comfort collectively. Decisions for managing patient comfort were influenced by their patients' overall hemodynamic stability.
Objectives: In a randomized single-center trial, we compared developmental and neurologic outcomes at 1 and 2 to 4 years of age in children who underwent reparative cardiac operations at less than 9 ...months of age after use of the alpha-stat versus pH-stat strategy during deep hypothermic cardiopulmonary bypass. Methods: Among 168 children eligible for follow-up, 1-year developmental evaluations were carried out on 111, neurologic evaluations on 110, and electroencephalographic evaluations on 102. Parents of 122 children completed questionnaires on behavior and development when children were 2 to 4 years of age. Results: The Psychomotor Development Index scores of the alpha-stat and pH-stat groups did not differ significantly (P =.97). For Mental Development Index scores, the treatment group effect differed according to diagnosis (P =.007). In the D -transposition of the great arteries (n = 59) and tetralogy of Fallot (n = 36) subgroups, the pH-stat group had slightly higher Mental Development Index scores than the alpha-stat group, although these differences were not statistically significant. In the ventricular septal defect subgroup (n = 16), the alpha-stat group had significantly higher scores. Psychomotor Development Index and Mental Development Index scores were significantly higher in the group with D -transposition of the great arteries than in the other 2 groups (P =.03 and P =.01, respectively). Across all diagnoses, Mental Development Index scores were significantly higher than Psychomotor Development Index scores (P <.001). Treatment group assignment was not significantly associated with abnormalities on neurologic examination (P =.70) or electroencephalographic examination (P =.77) at 1 year or with parents' ratings of children's development (P =.99) or behavior (P =.27) at age 2 to 4 years. Conclusions: Use of alpha-stat versus pH-stat acid-base management strategy during reparative infant cardiac operations with deep hypothermic cardiopulmonary bypass was not consistently related to either improved or impaired early neurodevelopmental outcomes. (J Thorac Cardiovasc Surg 2001;121:374-83)
Celiac disease (CD) results in enteropathy and malabsorption that can cause prandial insulin-glucose mismatch in patients with type 1 diabetes (T1D). This study leveraged continuous glucose ...monitoring (CGM) in children during the first year after T1D diagnosis to determine whether those with untreated CD have lower post-prandial glucose levels compared to those without CD. Children with T1D, positive CD serologies and biopsy-confirmed CD (CD+) were matched 1-to-4 to children with T1D but negative CD serologies (CD-) on age, sex, BMI and duration of diabetes. Meals were analyzed in the 30-day window before CD serologies and were computationally defined as paired CGM glucose peaks and troughs. Differences in the primary outcome, post-prandial trough, and other post-prandial glucose variables were assessed via log-linear mixed models. The cohort (N = 16 CD+, N = 64 CD-) was 69% female, with median age 10.7 years (interquartile range 8.9 - 12.8), T1D duration 4.1 months (2.3 - 7.7), and BMI z-score 0.29 (0.00 - 0.92). Over the 30-day window, mean post-prandial trough glucose and peak glucose were 111.7 mg/dL (SD 36.3) and 213.6 mg/dL (48.5) in the CD+ children, and 128.6 mg/dL (39.8) and 238.4 mg/dL (53.0) in the CD- children, respectively. In the repeated measures models, CD diagnosis reduced trough glucose by 12.8% (p = 0.059) and reduced peak glucose by 10.2% (p = 0.048). Other secondary outcomes including change in glucose or time from peak to trough did not significantly differ between groups. There is a quantifiable difference in post-prandial glucose when CD is present and untreated in patients with T1D. These findings can inform a future, CGM-based, predictive model of CD in T1D to prompt screening and aid in earlier diagnosis and treatment. Disclosure J. Ruiz: Research Support; Dexcom, Inc. L. Asaro: None. A. Bernique: None. S. Clemons: None. J.A. Silvester: Consultant; Takeda Pharmaceutical Company Limited. Research Support; Takeda Pharmaceutical Company Limited. Other Relationship; Wolters Kluwer Health. D. Wypij: None. M. Agus: Research Support; Dexcom, Inc. Funding Cystic Fibrosis Foundation ù Pediatric Scientist Development Program (K12-HD000850)
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