Clinical Practice Guideline Recommendations in Pediatric Mild Traumatic Brain Injury: A Systematic Review.

STUDY OBJECTIVE: Our primary objectives were to identify clinical practice guideline recommendations for children with acute mild traumatic brain injury (mTBI) presenting to an emergency department (ED), appraise their overall quality, and synthesize the quality of evidence and the strength of included recommendations. METHODS: We searched MEDLINE, EMBASE, Cochrane Central, Web of Science, and medical association websites from January 2012 to May 2023 for clinical practice guidelines with at least 1 recommendation targeting pediatric mTBI populations presenting to the ED within 48 hours of injury for any diagnostic or therapeutic intervention in the acute phase of care (ED and inhospital). Pairs of reviewers independently assessed overall clinical practice guideline quality using the Appraisal of Guidelines Research and Evaluation (AGREE) II tool. The quality of evidence on recommendations was synthesized using a matrix based on the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) Evidence-to-Decision framework. RESULTS: We included 11 clinical practice guidelines, of which 6 (55%) were rated high quality. These included 101 recommendations, of which 34 (34%) were based on moderate- to high-quality evidence, covering initial assessment, initial diagnostic imaging, monitoring/observation, therapeutic interventions, discharge advice, follow-up, and patient and family support. We did not identify any evidence-based recommendations in high-quality clinical practice guidelines for repeat imaging, neurosurgical consultation, or hospital admission. Lack of strategies and tools to aid implementation and editorial independence were the most common methodological weaknesses. CONCLUSIONS: We identified 34 recommendations based on moderate- to high-quality evidence that may be considered for implementation in clinical settings. Our review highlights important areas for future research. This review also underlines the importance of providing strategies to facilitate the implementation of clinical practice guideline recommendations for pediatric mTBI.

Clinical Practice Guideline Recommendations in Pediatric Orthopaedic Injury: A Systematic Review.

BACKGROUND: Lack of adherence to recommendations on pediatric orthopaedic injury care may be driven by lack of knowledge of clinical practice guidelines (CPGs), heterogeneity in recommendations or concerns about their quality. We aimed to identify CPGs for pediatric orthopaedic injury care, appraise their quality, and synthesize the quality of evidence and the strength of associated recommendations. METHODS: We searched Medline, Embase, Cochrane CENTRAL, Web of Science and websites of clinical organizations. CPGs including at least one recommendation targeting pediatric orthopaedic injury populations on any diagnostic or therapeutic intervention developed in the last 15 years were eligible. Pairs of reviewers independently extracted data and evaluated CPG quality using the Appraisal of Guidelines Research and Evaluation (AGREE) II tool. We synthesized recommendations from high-quality CPGs using a recommendations matrix based on the GRADE Evidence-to-Decision framework. RESULTS: We included 13 eligible CPGs, of which 7 were rated high quality. Lack of stakeholder involvement and applicability (i.e., implementation strategies) were identified as weaknesses. We extracted 53 recommendations of which 19 were based on moderate or high-quality evidence. CONCLUSIONS: We provide a synthesis of recommendations from high-quality CPGs that can be used by clinicians to guide treatment decisions. Future CPGs should aim to use a partnership approach with all key stakeholders and provide strategies to facilitate implementation. This study also highlights the need for more rigorous research on pediatric orthopaedic trauma. LEVEL OF EVIDENCE: Level II-therapeutic study.

Pediatric Moderate and Severe Traumatic Brain Injury: A Systematic Review of Clinical Practice Guideline Recommendations.

Traumatic brain injury (TBI) is the leading cause of death and disability in children. Many clinical practice guidelines (CPGs) have addressed pediatric TBI in the last decade but significant variability in the use of these guidelines persists. Here, we systematically review CPGs recommendations for pediatric moderate-to-severe TBI, evaluate the quality of CPGs, synthesize the quality of evidence and strength of included recommendations, and identify knowledge gaps. A systematic search was conducted in MEDLINE®, Embase, Cochrane CENTRAL, Web of Science, and Web sites of organizations publishing recommendations on pediatric injury care. We included CPGs developed in high-income countries from January 2012 to May 2023, with at least one recommendation targeting pediatric (≤ 19 years old) moderate-to-severe TBI populations. The quality of included clinical practice guidelines was assessed using the AGREE II tool. We synthesized evidence on recommendations using a matrix based on the Grading of Recommendations Assessment, Development and Evaluation (GRADE) framework. We identified 15 CPGs of which 9 were rated moderate to high quality using AGREE II. We identified 90 recommendations, of which 40 (45%) were evidence based. Eleven of these were based on moderate to high quality evidence and were graded as moderate or strong by at least one guideline. These included transfer, imaging, intracranial pressure control, and discharge advice. We identified gaps in evidence-based recommendations for red blood cell transfusion, plasma and platelet transfusion, thromboprophylaxis, surgical antimicrobial prophylaxis, early diagnosis of hypopituitarism, and mental health mangement. Many up-to-date CPGs are available, but there is a paucity of evidence to support recommendations, highlighting the urgent need for robust clinical research in this vulnerable population. Our results may be used by clinicians to identify recommendations based on the highest level of evidence, by healthcare administrators to inform guideline implementation in clinical settings, by researchers to identify areas where robust evidence is needed, and by guideline writing groups to inform the updating of existing guidelines or the development of new ones.

Clinical practice guideline recommendations for pediatric solid organ injury care: A Systematic Review.

BACKGROUND: Observed variations in the management of pediatric solid organ injuries (SOIs) may be due to difficulty in finding and integrating recommendations from multiple clinical practice guidelines (CPGs) with heterogeneous methodological approaches. We aimed to systematically review CPG recommendations for pediatric SOIs. METHODS: We conducted a systematic review of CPGs including at least one recommendation targeting pediatric SOI populations, using Medical Analysis and Retrieval System Online, Excerpta Medica dataBASE, Web of Science, and websites of clinical organizations. Pairs of reviewers independently assessed eligibility, extracted data, and evaluated the quality of CPGs using the Appraisal of Guidelines Research and Evaluation II tool. We synthesized recommendations from moderate to high-quality CPGs using a recommendations matrix based on Grades of Recommendation, Assessment, Development, and Evaluation criteria. RESULTS: We identified eight CPGs, including three rated moderate or high quality. Methodological weaknesses included lack of stakeholder involvement beyond surgeons, consideration of applicability (e.g., implementation tools), and clarity around the definition of pediatric populations. Five of the 15 recommendations from moderate to high-quality CPGs were based on moderate quality evidence or were rated as strong; these reflected nonoperative management and angioembolization for renal injuries and required length of stay for liver and spleen injuries. CONCLUSION: We identified 15 recommendations on pediatric SOI management from 3 moderate or high-quality CPGs, but only one third were based on at least moderate-quality evidence or were rated as strong. Our results prompt the following recommendations for future CPG development or updates: (1) include all types of clinicians involved in the care of pediatric SOIs and patient and family representatives in the process, (2) develop clear definitions of the target population, and (3) provide advice and tools to promote implementation. Results also underline the urgent need for more rigorous research to support strong evidence-based recommendations in this population. LEVEL OF EVIDENCE: Systematic Review/Meta-analysis; Level III.

Evolution of burnout and psychological distress in healthcare workers during the COVID-19 pandemic: a 1-year observational study.

BACKGROUND: Long-term psychological impacts of the COVID-19 pandemic on healthcare workers remain unknown. We aimed to determine the one-year progression of burnout and mental health since pandemic onset, and verify if protective factors against psychological distress at the beginning of the COVID-19 pandemic (Cyr et al. in Front Psychiatry; 2021) remained associated when assessed several months later. METHODS: We used validated questionnaires (Maslach Burnout Inventory, Hospital Anxiety and Depression and posttraumatic stress disorder [PTSD] Checklist for DSM-5 scales) to assess burnout and psychological distress in 410 healthcare workers from Quebec, Canada, at three and 12 months after pandemic onset. We then performed multivariable regression analyses to identify protective factors of burnout and mental health at 12 months. As the equivalent regression analyses at three months post-pandemic onset had already been conducted in the previous paper, we could compare the protective factors at both time points. RESULTS: Prevalence of burnout and anxiety were similar at three and 12 months (52% vs. 51%, p = 0.66; 23% vs. 23%, p = 0.91), while PTSD (23% vs. 11%, p < 0.0001) and depression (11% vs. 6%, p = 0.001) decreased significantly over time. Higher resilience was associated with a lower probability of all outcomes at both time points. Perceived organizational support remained significantly associated with a reduced risk of burnout at 12 months. Social support emerged as a protective factor against burnout at 12 months and persisted over time for studied PTSD, anxiety, and depression. CONCLUSIONS: Healthcare workers' occupational and mental health stabilized or improved between three and 12 months after the pandemic onset. The predominant protective factors against burnout remained resilience and perceived organizational support. For PTSD, anxiety and depression, resilience and social support were important factors over time.

Clinical practice guideline recommendations for pediatric injury care: protocol for a systematic review.

INTRODUCTION: Evidence suggests the presence of deficiencies in the quality of care provided to up to half of all paediatric trauma patients in Canada, the USA and Australia. Lack of adherence to evidence-based recommendations may be driven by lack of knowledge of clinical practice guidelines (CPGs), heterogeneity in recommendations or concerns about their quality. We aim to systematically review CPG recommendations for paediatric injury care and appraise their quality. METHODS AND ANALYSIS: We will identify CPG recommendations through a comprehensive search strategy including Medical Literature Analysis and Retrieval System Online, Excerpta Medica dataBASE, Cochrane library, Web of Science, ClinicalTrials and websites of organisations publishing recommendations on paediatric injury care. We will consider CPGs including at least one recommendation targeting paediatric injury populations on any diagnostic or therapeutic intervention from the acute phase of care with any comparator developed in high-income countries in the last 15 years (January 2007 to a maximum of 6 months prior to submission). Pairs of reviewers will independently screen titles, abstracts and full text of eligible articles, extract data and evaluate the quality of CPGs and their recommendations using Appraisal of Guidelines Research and Evaluation (AGREE) II and AGREE Recommendations Excellence instruments, respectively. We will synthesise evidence on recommendations using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) Evidence-to-Decision framework and present results within a recommendations matrix. ETHICS AND DISSEMINATION: Ethics approval is not a requirement as this study is based on available published data. The results of this systematic review will be published in a peer-reviewed journal, presented at international scientific meetings and distributed to healthcare providers. PROSPERO REGISTRATION NUMBER: International Prospective Register of Systematic Reviews (CRD42021226934).

Hair cortisol change at COVID-19 pandemic onset predicts burnout among health personnel.

BACKGROUND: The COVID-19 pandemic has put chronic pressure on worldwide healthcare systems. While the literature regarding the prevalence of psychological distress and associated risk factors among healthcare workers facing COVID-19 has exploded, biological variables have been mostly overlooked. METHODS: 467 healthcare workers from Quebec, Canada, answered an electronic survey covering various risk factors and mental health outcomes three months after the onset of the COVID-19 pandemic. Of them, 372 (80%) provided a hair sample, providing a history of cortisol secretion for the three months preceding and following the pandemic's start. We used multivariable regression models and a receiver operating characteristic curve to study hair cortisol as a predictor of burnout and psychological health, together with individual, occupational, social, and organizational factors. RESULTS: As expected, hair cortisol levels increased after the start of the pandemic, with a median relative change of 29% (IQR = 3-59%, p < 0.0001). There was a significant association between burnout status and change in cortisol, with participants in the second quarter of change having lower odds of burnout. No association was found between cortisol change and post-traumatic stress disorder, anxiety, and depression symptoms. Adding cortisol to individual-occupational-socio-organizational factors noticeably enhanced our burnout logistic regression model's predictability. CONCLUSION: Change in hair cortisol levels predicted burnout at three months in health personnel at the onset of the COVID-19 pandemic. This non-invasive biological marker of the stress response could be used in further clinical or research initiatives to screen high-risk individuals to prevent and control burnout in health personnel facing an important stressor.

Sleep Instability Correlates with Attentional Impairment in Boys with Attention Deficit Hyperactivity Disorder.

Theoretical models of sleep and attention deficit hyperactivity disorder (ADHD) suggest that symptoms of ADHD are associated with daytime sleepiness, but it has received little support. The present study aimed at testing an alternative model involving the association of attentional instability with sleep instability, i.e., sleep stage transitions and arousals. Twelve ADHD and 15 healthy control (HC) boys aged between 8 and 12 years old underwent polysomnography recording and attentional testing. The microarousal index, the number of awakenings, and the number of stage shifts between stages 1, 2, 3, 4 and REM sleep throughout the night were computed as sleep stability parameters. Attentional functioning was assessed using the Continuous Performance Test-II. We found significantly higher sleep instability in ADHD compared to HC. Sleep arousals and stage transitions (micro arousal index, stage 4/3 and 2/4 transitions) in ADHD significantly correlated with lower attentional scores. No association whatsoever was found between sleep instability and attentional functioning in HC. The results show that sleep instability is associated with lower attentional performance in boys with ADHD, but not in HC. This could be compatible with a model according to which attention and sleep stability share a common neural substrate in ADHD.

Factors Associated With Burnout, Post-traumatic Stress and Anxio-Depressive Symptoms in Healthcare Workers 3 Months Into the COVID-19 Pandemic: An Observational Study.

Objective: This study examined how best to identify modifiable protective and risk factors for burnout in healthcare workers in the face of the COVID-19 pandemic. Individual, occupational, organizational and social factors were investigated. The study also assessed the impact of these factors on post-traumatic stress disorder (PTSD), anxiety, and depression. Methods: Healthcare workers in the Quebec (Canada) healthcare system were recruited between May 21 to June 5, 2020. Participants answered an electronic survey 3 months after the COVID-19 epidemic outbreak began in Canada. Using the Maslach Burnout Inventory, PTSD Checklist for DSM-5, and Hospital Anxiety and Depression Scale, we studied the prevalence of burnout, PTSD, anxiety and depression in this cohort. Multivariable logistic or linear regression models including resilience, social and organizational support, workload and access to mental health help, simulation techniques and protective personal equipment (PPE) as well as perception of PPE security were conducted for each outcome. Results: In mid-June 2020, 467 participants completed the survey. We found that half (51.8%) of the respondents experienced burnout characterized by emotional exhaustion and/or depersonalization at least once a week. In total, 158 healthcare workers (35.6%) displayed severe symptoms of at least one of the mental health disorders (24.3% PTSD, 23.3% anxiety, 10.6% depression). Resilience (OR = 0.69, 95% CI: [0.55-0.87]; p = 0.002) and perceived organizational support (OR = 0.75, 95% CI: [0.61-0.93]; p = 0.009) were significantly associated with burnout and other outcomes. Social support satisfaction, perception of PPE security, work type and environment, mental health antecedents and reassignment were associated with PTSD and/or anxiety and/or depression, but not burnout. Conclusion: Future studies should address primarily resilience and perceived organizational support to promote mental health and prevent burnout, PTSD, anxiety and depression.

Point-of-care ultrasound before attempting clean-catch urine collection in infants: a randomized controlled trial.

OBJECTIVE: A new non-invasive bladder stimulation technique has been described to obtain clean-catch urine specimens in infants. This study aimed to evaluate if point-of-care ultrasound (POCUS) guided feeding protocol to measure bladder volume prior to stimulation techniques improves clean-catch urine collection success. METHODS: A prospective randomized controlled trial study was conducted in a tertiary care pediatric emergency department. Infants aged less than 6 months needing a urine sample were randomized to either POCUS group or feeding group (standard procedure) before performing a standardized clean-catch urine stimulation technique. In the POCUS group, a feeding period was permitted if the bladder width was less than 2 cm, otherwise the clean-catch urine was performed immediately. The primary outcome was the success of the procedure defined by the collection of at least 2 mL of urine, obtained within 300 seconds of bladder stimulation manoeuvres. It was estimated that the recruitment of 200 children was necessary to yield 80% power to identify an improvement of 20% in the success rate. RESULTS: A total of 201 infants were included. The procedure was not more successful in the POCUS group (48%) compared to the feeding group (54%) (Difference: 6.5%; 95% CI: -7.3 to 19.8%). The mean time to collect urine samples from randomization to sample collection was not different between the two groups. CONCLUSIONS: Our study failed to show a benefit of using POCUS to improve the success rate of stimulated clean-catch urine. Moreover, the importance of the feeding period prior to clean-catch urine manoeuvres should be evaluated further. CLINICAL TRIAL REGISTRATION: NCT02751671.

OBJECTIF: Une nouvelle technique de prélèvement urinaire non-invasive par mi-jet stimulé fut décrite pour les nourrissons. L'étude visait à évaluer si un protocole d'allaitement guidé par l'échographie au chevet (EC), avant stimulation, pour mesurer le volume de la vessie, permettait d'accroître le taux de réussite du recueil d'urine par mi-jet. MÉTHODE: Un essai comparatif, prospectif et à répartition aléatoire a été mené dans un service des urgences pédiatriques de soins tertiaires. Des nourrissons âgés de moins de 6 mois chez qui devait être pratiqué un prélèvement d'urine ont été répartis au hasard dans le groupe de l'EC ou dans le groupe d'allaitement (méthode courante) avant que ne soit pratiquée la technique de stimulation uniforme de recueil d'urine par mi-jet. Dans le groupe de l'EC, l'allaitement était permis si la largeur de la vessie était < 2 cm; sinon, l'on procédait immédiatement au recueil d'urine par mi-jet stimulé. Le principal critère d'évaluation consistait en la réussite du prélèvement, défini comme le recueil d'au moins 2 ml d'urine pendant les manœuvres de stimulation de la vessie, d'une durée maximum de 300 secondes. D'après l'évaluation des chercheurs, le nombre de sujets nécessaire pour que l'étude atteigne une puissance de 80% et mette ainsi en évidence une augmentation de 20% du taux de réussite devait s'élever à 200. RÉSULTATS: Au total, 201 nourrissons ont participé à l'étude. Le recueil d'urine n'était pas plus élevé dans le groupe de l'EC (48%) que dans le groupe d'allaitement (54%) (écart : 6,5%; IC à 95% : -7,3% à 19,8%). Il n'y avait de différence non plus entre les deux groupes quant au temps moyen écoulé depuis la répartition aléatoire des sujets jusqu'au prélèvement d'urine. CONCLUSION: La supériorité de l'EC dans l'accroissement du taux de réussite du recueil d'urine non souillée par stimulation n'a pas été démontrée dans l'étude. Il faudrait aussi évaluer davantage l'importance de la durée de l'allaitement avant les manœuvres de recueil d'urine non souillée. NO D'ENREGISTREMENT DES ESSAIS CLINIQUES: NCT02751671.

Comorbidity of ADHD and Anxiety Disorders in School-Age Children: Impact on Sleep and Response to a Cognitive-Behavioral Treatment.

OBJECTIVE: This exploratory study measured the impact of comorbid anxiety disorders on sleep in children with ADHD and tested the effect of cognitive-behavioral therapy (CBT) on these measures. METHOD: Fifty-seven children (8-12 years old) were assessed with the Child Sleep Habits Questionnaire. Four groups were formed: ADHD ( n = 20), ADHD + Anxiety ( n = 20), Anxiety ( n = 8), and Healthy Controls ( n = 9). A subgroup of 10 children with ADHD + Anxiety underwent CBT for anxiety. RESULTS: The results showed that sleep difficulties were better associated with anxiety than with ADHD. CBT reduced sleep onset latency and marginally decreased the total amount of sleep problems. CONCLUSION: The present study demonstrates that comorbid anxiety in ADHD children is linked with specific sleep disturbances and is sensitive to CBT aimed at reducing anxiety.

Evaluation of a New Strategy for Clean-Catch Urine in Infants.

BACKGROUND AND OBJECTIVES: A new noninvasive bladder stimulation technique has been described to obtain clean-catch urine (CCU) in infants aged <30 days. Objectives were (1) to determine proportion and predictive factors for successful CCU collections using a stimulation maneuver technique among infants <6 months and (2) to determine the proportion of bacterial contamination with this method. METHODS: A prospective cohort study was conducted in a tertiary pediatric emergency department among infants <6 months needing a urine sample. CCU samples were collected using a standardized stimulation technique. Invasive technique was performed after CCU for three specific conditions. Primary outcomes were proportions of successful CCU specimens and bacterial contamination. We determined associations between successful urine samples and 4 predictive factors (age, sex, low oral intake, and recent voiding). RESULTS: A total of 126 infants were included (64 boys, median age: 55 days). The CCU procedure was effective in 62 infants (49%; median time: 45 seconds). Infants 0 to 29 days; 30 to 59 days, and 60 to 89 days had more successful procedures, compared with infants >89 days (odds ratios [95% confidence interval (CI)]: 4.3 [1.4 to 13.4]; 3.2 [1.2 to 8.4]; and 4.44 [1.5 to 13.3], respectively). The contamination proportion was 16% (95% CI: 8% to 27%) in the CCU group. This proportion was not statistically different compared with the invasive method group (6%, 95% CI: 3% to 15%). CONCLUSIONS: The CCU procedure is a quick and effective noninvasive method in children aged <90 days. Contamination proportions were similar to those reported in the literature for urethral catheterization. Circumstances for which the CCU procedure could be performed are proposed.

Developmental delay and magnocellular visual pathway function in very-low-birthweight preterm infants.

This study investigated the effect of very preterm birth (gestation < or =30wks) and very low birth weight (< or =1500g) on the development of magnocellular and parvocellular visual processing streams. Participants were preterm infants (n=55: 31 females, 24 males) born between 24 and 30 weeks'gestation (mean 27.4wks [SD 1.3]), weighing between 720 and 1470g (mean 1015g [SD 215]) and term infants (n=52: 27 females, 25 males) born between 38 and 42 weeks'gestation (mean 39.4wks [SD 0.9]), weighing between 2670 and 4405g (mean 3549g [SD 440]). Visual-evoked potentials to phase-reversing sine-wave gratings, varying in spatial frequency and contrast, were used to elicit magnocellular and parvocellular specific responses. Previous studies found that the N1 component reflects the parvocellular response, while P1 reflects the magnocellular response in adults and infants. Findings from the current study indicate significantly lower P1 amplitudes in preterm compared with term infants under most conditions. No difference was found for the amplitude of the N1 waveform. Results indicate that, for the age-range tested, preterm birth has little effect on the development of parvocellular function, while it appears to disrupt the development of magnocelluar function.

Magnocellular and parvocellular developmental course in infants during the first year of life.

The visual system undergoes major modifications during the first year of life. We wanted to examine whether the magnocellular (M) and parvocellular (P) pathways mature at the same rate or if they follow a different developmental course. A previous study carried out in our laboratory had shown that the N1 and P1 components of pattern visual evoked potentials (PVEPs) were preferentially related to the activity of P and M pathways, respectively. In the present study, PVEPs were recorded at Oz in 33 infants aged between 0 and 52 weeks, in response to two spatial frequencies (0.5 and 2.5 c deg(-1)) presented at four contrast levels (4, 12, 28 and 95%). Results indicate that the P1 component appeared before the N1 component in the periods tested and was unambiguously present at birth. The P1 component showed a rapid gain in amplitude in the following months, to reach a ceiling around 4-6 months. Conversely, the N1 component always appeared later and then gained in amplitude until the end of the first year without reaching a plateau. Latencies were also computed but no developmental dissociation was revealed. Results obtained on amplitude are interpreted as demonstrating a developmental dissociation between the underlying M and P pathways, suggesting that the former is functional earlier and matures faster than the latter during the first year of life.