A study protocol for risk stratification in children with concussion (RSiCC): Theoretical framework, design, and methods.

Research shows that one in five children will experience a concussion by age 16. Compared to adults, children experience longer and more severe postconcussive symptoms (PCS), with severity and duration varying considerably among children and complicating management of these patients. Persistent PCS can result in increased school absenteeism, social isolation, and psychological distress. Although early PCS diagnosis and access to evidence-based interventions are strongly linked to positive health and academic outcomes, symptom severity and duration are not fully explained by acute post-injury symptoms. Prior research has focused on the role of neuroinflammation in mediating PCS and associated fatigue; however relationship between inflammatory biomarkers and PCS severity, has not examined longitudinally. To identify which children are at high risk for persistent PCS and poor health, academic, and social outcomes, research tracking PCS trajectories and describing school-based impacts across the entire first year postinjury is critically needed. This study will 1) define novel PCS trajectory typologies in a racially/ethnically diverse population of 500 children with concussion (11-17 years, near equal distribution by sex), 2) identify associations between these typologies and patterns of inflammatory biomarkers and genetic variants, 3) develop a risk stratification model to identify children at risk for persistent PCS; and 4) gain unique insights and describe PCS impact, including fatigue, on longer-term academic and social outcomes. We will be the first to use NIH's symptom science model and patient-reported outcomes to explore the patterns of fatigue and other physical, cognitive, psychological, emotional and academic responses to concussion in children over a full year. Our model will enable clinicians and educators to identify children most at risk for poor long-term health, social, and academic outcomes after concussion. This work is critical to meeting our long-term goal of developing personalized concussion symptom-management strategies to improve outcomes and reduce disparities in the health and quality of life of children.

Impact of Continuous Renal Replacement Therapy Initiation Time, Kidney Injury, and Hypervolemia in Critically Ill Children.

BACKGROUND: The mortality rate of pediatric patients who require continuous renal replacement therapy is approximately 42%, and outcomes vary considerably depending on underlying disease, illness severity, and time of dialysis initiation. Delay in the initiation of such therapy may increase mortality risk, prolong intensive care unit stay, and worsen clinical outcomes. LOCAL PROBLEM: In the pediatric intensive care unit of an urban level I trauma children's hospital, continuous renal replacement therapy initiation times and factors associated with delays in therapy were unknown. METHODS: This quality improvement process involved a retrospective review of data on patients who received continuous dialysis in the pediatric intensive care unit from January 1, 2017, to December 31, 2021. The objectives were to examine the characteristics of the children requiring continuous renal replacement therapy, therapy initiation times, and factors associated with initiation delays that might affect unit length of stay and mortality. RESULTS: During the study period, 175 patients received continuous renal replacement therapy, with an average initiation time of 11.9 hours. Statistically significant associations were found between the degree of fluid overload and mortality (P < .001) and between the presence of acute kidney injury and prolonged length of stay (P = .04). No significant association was found between therapy initiation time and unit length of stay or mortality, although the average initiation time of survivors was 5.9 hours shorter than that of nonsurvivors. CONCLUSION: Future studies are needed to assess real time delays and to evaluate if the implementation of a standardized initiation process decreases initiation time.

Association of hydroxyurea adherence with transcranial Doppler screenings in children with sickle cell disease.

BACKGROUND: National sickle cell disease (SCD) guidelines recommend oral hydroxyurea (HU) starting at 9 months of age, and annual transcranial Doppler (TCD) screenings to identify stroke risk in children aged 2-16 years. We examined prevalence and proportion of TCD screenings in North Carolina Medicaid enrollees to identify associations with sociodemographic factors and HU adherence over 3 years. STUDY DESIGN: We conducted a longitudinal study with children ages 2-16 years with SCD enrolled in NC Medicaid from years 2016-2019. Prevalence of TCD screening claims was calculated for 3 years, and proportion was calculated for 12, 24, and 36 months of Medicaid enrollment. Enrollee HU adherence was categorized using HU proportion of days covered. Multivariable Poisson regression assessed for TCD screening rates by HU adherence, controlling for age, sex, and rurality. RESULTS: The prevalence of annual TCD screening was between 39.5% and 40.1%. Of those with 12-month enrollment, 77.8% had no TCD claims, compared to 22.2% who had one or higher TCD claims. Inversely, in children with 36 months of enrollment, 36.7% had no TCD claims compared to 63.3% who had one or higher TCD claims. The proportion of children with two or higher TCD claims increased with longer enrollment (10.5% at 12 months, 33.7% at 24 months, and 52.6% at 36 months). Children with good HU adherence were 2.48 (p < .0001) times more likely to have TCD claims than children with poor HU adherence. CONCLUSION: While overall TCD screening prevalence was low, children with better HU adherence and longer Medicaid enrollment had more TCD screenings. Multilevel interventions are needed to engage healthcare providers and families to improve both evidence-based care and annual TCD screenings in children with SCD.

An Approach to Diversifying the Selection of a Guideline Panel-The Process Utilized for the Updated Adult Critical Care Ultrasound Guidelines.

OBJECTIVES: Clinical practice guidelines are essential for promoting evidence-based healthcare. While diversification of panel members can reduce disparities in care, processes for panel selection lack transparency. We aim to share our approach in forming a diverse expert panel for the updated Adult Critical Care Ultrasound Guidelines. DESIGN: This process evaluation aims to understand whether the implementation of a transparent and intentional approach to guideline panel selection would result in the creation of a diverse expert guideline panel. SETTING: This study was conducted in the setting of creating a guideline panel for the updated Adult Critical Care Ultrasound Guidelines. PATIENTS: Understanding that family/patient advocacy in guideline creations can promote the impact of a clinical practice guideline, patient representation on the expert panel was prioritized. INTERVENTIONS: Interventions included creation of a clear definition of expertise, an open invitation to the Society of Critical Care Medicine membership to apply for the panel, additional panel nomination by guideline leadership, voluntary disclosure of pre-identified diversity criteria by potential candidates, and independent review of applications including diversity criteria. This resulted in an overall score per candidate per reviewer and an open forum for discussion and final consensus. MEASUREMENTS AND MAIN RESULTS: The variables of diversity were collected and analyzed after panel selection. These were compared with historical data on panel composition. The final guideline panel comprised of 33 panelists from six countries: 45% women and 79% historically excluded people and groups. The panel has representation from nonphysician professionals and patients advocates. Of the healthcare professionals, there is representation from early, mid, and late career stages. CONCLUSIONS: Our intentional and transparent approach resulted in a panel with improved gender parity and robust diversity along ethnic, racial, and professional lines. We hope it can serve as a starting point as we strive to become a more inclusive and diverse discipline that creates globally representative guidelines.

Maternal Psychological Symptom Trajectories From 2 to 24 Months Postpartum: A Latent Class Growth Analysis.

BACKGROUND: Postpartum women experience an array of psychological symptoms that are associated with adverse health behaviors and outcomes including postpartum suicidal ideation and long-term depression. To provide early management of postpartum psychological symptoms, it is important to understand how the symptom experiences change over time. OBJECTIVE: The aim of this study was to examine maternal psychological symptom trajectories over 2, 6, 15, and 24 months postpartum using latent class growth analysis and to examine how each trajectory is associated with maternal depression outcome at 24 months. METHODS: We used secondary data from the Family Life Project ( N = 1,122) and performed multitrajectory latent class growth analysis based on four observed symptom variables (depression, anxiety, somatization, and hostility). After the final model was identified, bivariate analyses were conducted to examine the association between each trajectory and (a) individual characteristics and (b) outcome (Center for Epidemiologic Studies Depression Scale [CES-D]) variables. RESULTS: A four-class model was selected for the final model because it had better fit indices, entropy, and interpretability. The four symptom trajectories were (a) no symptoms over 24 months, (b) low symptoms over 24 months, (c) moderate symptoms increasing over 15 months, and (d) high symptoms increasing over 24 months. More postpartum women with the trajectory of high symptoms increasing over 24 months (Trajectory 4) were in low economic status (92.16%), unemployed (68.63%), or did not complete 4-year college education (98.04%). Most postpartum women (95.56%) in Trajectory 4 also had higher CES-D cutoff scores, indicating a possible clinical depression at 24 months postpartum. DISCUSSION: Postpartum women who experience increasing symptom trajectories over 15-24 months (Trajectories 3 and 4) could benefit from tailored symptom management interventions provided earlier in the postpartum period to prevent persistent and worsening symptom experiences.

Examination of Social Determinants of Health Characteristics Influencing Maternal Postpartum Symptom Experiences.

Postpartum women experience multiple, co-occurring postpartum symptoms. It is unknown if social determinants of health (SDOH) influence postpartum symptom typologies. This secondary analysis used the Community and Child Health Network study data. Participants included for analysis varied depending on the availability of the SDOH data (N = 851 to 1784). Bivariate and multiple regression analyses were conducted to examine the association between SDOH and previously identified postpartum symptom typologies. Area under the receiver operating characteristics curve (AUROC) was calculated to examine if adding SDOH variables contributes to predicting postpartum symptom typologies. The adjusted odds (aOR) of being in high symptom severity or occurrence typologies were greater for participants who had less than high school education (aOR = 2.29), experienced healthcare discrimination (aOR = 2.21), used governmental aid (aOR = 2.11), or were food insecure (aOR = 2.04). AUROC improved after adding SDOH. Considering experiences of different social-economic hardships influence postpartum symptom typologies, future practice and research should address SDOH to improve postpartum symptom experiences.

Changes in maternal psychological symptom profiles from 2 to 6 months postpartum: an application of latent transition analysis.

To identify subgroups of postpartum women with different psychological symptom profiles at 2 and 6 months postpartum and to examine how they transition between symptom profiles over time using latent transition analysis (LTA). We used secondary data from the Family Life Project (N = 1,117) and performed LTA based on observed variables (depression, anxiety, somatization, and hostility). We examined transition probabilities and changes in latent status prevalence from 2 to 6 months postpartum. Considering the known influences of social determinants of health on psychological symptoms, bivariate analyses were conducted to describe the characteristics of different transition patterns. A 3-class model with better fit indices, entropy, and interpretability was selected. Based on symptom severity, the identified profiles were Profile 1: Low, Profile 2: Moderate, and Profile 3: High. From 2 to 6 months postpartum, the prevalence of low symptom profile decreased (82 to 78.2%) while the prevalence increased for moderate (15.8 to 17.5%) and high symptom profiles (2.2 to 4.4%). For all profiles, it was most likely for postpartum women to stay in the same profile from 2 to 6 months (low to low, moderate to moderate, and high to high). Those in persistent or worsening transition patterns were significantly younger or had less social support or education. Postpartum women in moderate or high symptom profiles at 2 months were most likely to stay in the same profile at 6 months postpartum, indicating persistent symptom burden. Clinicians should consider providing early, targeted support to prevent persistent symptom burden.

Examination of Maternal Allostatic Load Among Postpartum Women With Distinct Postpartum Symptom Typologies.

BACKGROUND: An increased allostatic load (cumulative physiologic wear and tear of the body) can lead to adverse health outcomes. Symptom experiences are known to influence allostatic load. Yet, the relationships between postpartum symptom typologies and maternal allostatic load remain unknown. METHODS: We used Community Child Health Network data and included participants with allostatic load data at 6, 12, or 24 months postpartum. Bivariate and multivariate analyses were conducted to examine associations between postpartum symptom typologies and (a) overall allostatic load, (b) allostatic load subscales for body systems (neuroendocrine, cardiovascular, metabolic, and inflammatory), and (c) individual biomarkers within the subscale. RESULTS: Overall allostatic load at 12 months postpartum was different by symptom typologies before (p = .042) and after adjusting for confounders (p = .029). Postpartum women in typology 5 (high overall) had the highest adjusted overall allostatic load (M = 4.18, SE = .27). At 12 months, adjusted allostatic load for the cardiovascular subscale was higher in typologies 3 (moderate-high sleep symptoms, M = 1.78, SE = .13) and 5 (high overall, M = 1.80, SE = .17). Within the cardiovascular subscale, those in typology 3 had higher adjusted odds for a clinically significant level of pulse rate (aOR = 2.01, CI = 1.22, 3.31). CONCLUSION: Postpartum women who experienced high symptom severity across all symptoms (typology 5) at 6 months had higher overall allostatic load at 12 months postpartum. Typologies 3 and 5 had the highest symptom severity in sleep-related symptoms and higher cardiovascular subscale scores. Postpartum symptom management should target symptom burden in an effort to reduce allostatic load thereby improving postpartum women's health outcomes.

Identification of postpartum symptom subgroups and associated long-term maternal depressive symptoms and well-being.

Many postpartum women experience postpartum symptoms which often occur in clusters (i.e., three or more co-occurring symptoms that are related to each other). To date, research has focused on individual symptoms, which limits our understanding of how postpartum symptom clusters manifest and influence health. This secondary analysis used the Community and Child Health Network study data (N = 1784). No patient or public directly participated or contributed to the current analysis. Guided by the Symptom Management Theory, latent class analysis was performed to identify subgroups of postpartum women with different symptom experiences using observed variables at 6 months postpartum: anxiety (MINI-anxiety), general stress (PSS-10), posttraumatic stress (PCL-C), postpartum depression (EPDS), sleep disturbance (PSQI-sleep disturbance), and sleep duration (PSQI-sleep duration). Bivariate and multiple regression analyses were conducted to examine the association between subgroups and (a) individual characteristics and (b) long-term depressive symptoms (CES-D-9) and well-being at 18 and/or 24 months postpartum. Five subgroups were selected that had better-fit indices, entropy, and interpretability. Subgroups were labeled as (1) Minimum overall, (2) Mild-moderate overall, (3) Moderate-high sleep symptoms, (4) High psychological symptoms, and (5) High overall. After adjusting for covariates, postpartum women in Subgroups 4 and 5 had higher CES-D-9 scores at 18 and 24 months and lower well-being scores at 24 months. More postpartum women in Subgroups 4 and 5 experienced a history of depression or unemployment. Clinicians should provide targeted interventions for postpartum women in high-symptom subgroups.

Envisioning career trajectory post-PhD in nursing: Lessons learned from a professional development project.

BACKGROUND: Nursing Doctor of Philosophy (PhD) students can pursue diverse career opportunities within and outside of academia upon graduation. However, mentor-mentee models, competing demands, and limited resources can challenge students as they search for guidance in navigating career decisions. This article describes the development, implementation, and evaluation of a project to support PhD nursing career development. METHODS: A student-designed project was implemented over 4 weeks which aligned with four career trajectories that students identified. Descriptive statistics were used to analyze quantitative survey questions. Responses to open-ended questions and field notes were also examined. RESULTS: Post-implementation survey data suggested that all participants found the sessions helpful and recommended providing the workshop annually. Students' questions focused on three areas: job searches, job selection, and experiences once in a career trajectory. Workshop speakers' discussions focused on important tasks and strategies and wisdom and personal reflections offered to PhD students. DISCUSSION: Nursing PhD students are interested in diverse career trajectories beyond academia and valued an opportunity to explore these options outside of the traditional mentor-mentee relationship. Leveraging resources from schools of nursing and the broader collegiate environment is important in helping students to explore potential career trajectories.

Postpartum symptom clusters in birthing individuals: A systematic review.

BACKGROUND: Birthing individuals experience various postpartum symptoms which have been associated with adverse health outcomes. Previous systematic reviews have focused on the examination of individual symptoms and their impact on health, which have limited our understanding of postpartum symptom clusters. OBJECTIVE: To examine the compositions of symptom clusters, analytic methodologies and predictors of symptom clusters in birthing individuals up to 1 year postpartum. DESIGN: Systematic review. METHODS: This systematic review was reported following the PRISMA. Five databases were searched: PubMed, Embase, CINAHL Complete, PsycINFO and Scopus. Two reviewers performed title and abstract and full-text screening independently. Standard Quality Assessment Criteria were used to assess the articles' qualities. Key information was extracted into evidence table, which was checked for accuracy and completeness. A narrative synthesis was conducted. RESULTS: A total of 30 articles were included. Studies were conducted in 16 countries, mostly in Europe (n = 9) and North America (n = 7). The majority were quantitative (n = 27) and cross-sectional (n = 27). Factor analysis was the most frequently used analytic methodology (n = 21). All three qualitative studies used grounded theory. Taking into consideration the variations among the studies, stress (n = 15, infant or partner-related and from other sources), depression (n = 12), somatic (n = 12) and anxiety clusters (n = 10) were most frequently identified. Symptom cluster predictors were examined in less than half of the included studies (n = 13). Among these, most were focused on how individual postpartum symptoms influence symptom clusters. CONCLUSIONS: Stress, depression, somatic and anxiety clusters are the most frequently identified postpartum symptom clusters. Future studies should examine the consistency, stability and clinical meaningfulness of these four symptom clusters. RELEVANCE TO CLINICAL PRACTICE: The identification and management of the four symptom clusters should be of particular interest to clinicians and researchers. NO PATIENT OR PUBLIC CONTRIBUTION: This systematic review did not directly involve patient or public contribution to the manuscript.

Association between Day-to-Day Pulsatility Index Change and Neurocognitive Outcomes in Pediatric Traumatic Brain Injury.

Traumatic brain injury (TBI) remains a significant cause of morbidity and mortality in children despite advances in prevention and mitigation strategies. Transcranial Doppler (TCD) ultrasound measures cerebral arterial circulation and allows for the calculation of pulsatility indices (PIs), which provides an assessment of cerebral blood flow changes. Yet, the use of PIs in children with TBI is not well understood. In this study, we defined the day-to-day (DTD) PI change of the anterior cerebral circulation and describe its relationship with injury characteristics and neurocognitive outcomes in children with TBI. A prospective observational parent study of 42 children, 2 months to 15 years of age, with mild or moderate-severe TBI who had serial TCDs provided data for this analysis. Both the mean and variation of DTD PI change were evaluated in the context of injury severity, injury sidedness, and neurocognitive outcome. In those with a unilateral injury, a larger mean DTD PI change in both the injured and uninjured side was found in those with a worse Glasgow Outcome Scale-Extended Pediatrics score at discharge. A larger variation in PI was associated with a worse neurocognitive outcome, irrespective of injury severity. Therefore, the mean and variation of DTD PI change may serve as a potential cerebral vascular biomarker of ongoing secondary injury. The use of PI measurements in the monitoring of children with TBI may provide clinicians with new diagnostic and prognostic insights to inform therapeutic interventions and recovery strategies. However, a larger prospective study is needed to confirm these findings and elucidate potential mechanistic links between DTD PI and clinical outcome measures. To our knowledge, this study is the first of its kind to evaluate the use of PI changes in cerebral vasculature in pediatric TBI patients admitted to the hospital.

Acute Care Pediatric Nurse Practitioner: The 2018 Practice Analysis.

INTRODUCTION: Practice research serves as the certification framework for validating advanced practice roles and updating national qualifying examinations. This national study informed an update of the Certified Pediatric Nurse Practitioner - Acute Care (CPNP-AC) examination content outline. METHOD: A descriptive analysis of a survey completed in 2018 by 373 pediatric nurse practitioners (PNP) practicing as an acute care role (AC). RESULTS: Respondents were primarily females aged 25 to 34 years (35.4%) and formally educated as AC PNPs (84.2%) and held the CPNP-AC credential (98.9%). Most respondents (83.6%) practiced in urban areas and spent 84% of their time in direct patient care with 74% working in inpatient settings. The majority (87%) worked in subspecialty practice such as critical care (18.5%) and cardiac intensive care (12.3%). DISCUSSION: This is the fourth practice analysis of the AC PNP role that demonstrates continuous evolution in clinical practice, educational preparation, and subspecialty practice distribution.

Practice Recommendations for Transcranial Doppler Ultrasonography in Critically Ill Children in the Pediatric Intensive Care Unit: A Multidisciplinary Expert Consensus Statement.

Transcranial Doppler ultrasonography (TCD) is being used in many pediatric intensive care units (PICUs) to aid in the diagnosis and monitoring of children with known or suspected pathophysiological changes to cerebral hemodynamics. Standardized approaches to scanning protocols, interpretation, and documentation of TCD examinations in this setting are lacking. A panel of multidisciplinary clinicians with expertise in the use of TCD in the PICU undertook a three-round modified Delphi process to reach unanimous agreement on 34 statements and then create practice recommendations for TCD use in the PICU. Use of these recommendations will help to ensure that high quality TCD images are captured, interpreted, and reported using standard nomenclature. Furthermore, use will aid in ensuring reproducible and meaningful study results between TCD practitioners and across PICUs.

Day-to-Day Change in Pulsatility Index Describes Anterior Cerebral Circulation Disturbance and Functional Outcomes in Pediatric Traumatic Brain Injury.

BACKGROUND: Traumatic brain injury (TBI) is a significant source of morbidity and mortality in children. Transcranial Doppler (TCD) ultrasound measures the cerebral arterial circulation allowing for the calculation of pulsatility indices (PIs) that provide an assessment of cerebral blood flow alterations. However, the use of PI in children with TBI is poorly understood and may be an important measure for the nursing care of children. OBJECTIVES: The purpose of this article is to define day-to-day PI change and to describe its relationship to injury characteristics and functional outcomes in children with TBI. METHOD: We performed a secondary analysis of a prospective observational parent study of 40 children aged 2 months to 15 years with mild or moderate-severe TBI who had serial TCDs. Sequential TCD PI measurements of day-to-day change revealed several consistencies among the TBI severity groups. RESULTS: Day-to-day PI change was higher in children with a moderate-severe injury (40%) when compared with those with a mild injury (21%). Greater day-to-day PI change was seen in children whose Glasgow Outcome Scale-Extended Pediatrics scores worsened (25%) compared with those who had an improved (19%) or unchanged (23%) scores. DISCUSSION: This study is the first to report day-to-day PI change in children with TBI and provides early insights into anterior cerebral artery circulation alterations of children with TBI. Although further research is needed, this study provides early evidence that TCD may be a valuable noninvasive neuromonitoring option in the management of children with TBI.

Sleep in the Intensive Care Unit: Biological, Environmental, and Pharmacologic Implications for Nurses.

There is a clear relationship between lack of sleep, poor health outcomes, and delayed recovery from illness in the intensive care unit. Several factors can contribute to poor quality sleep in the intensive care unit, including (1) environmental disruptions such as light and sound, (2) physiologic disruptions such as discomfort, nausea, and pain, (3) psychological disruptions such as anxiety and a lack of privacy, and (4) health care provider-related disruptions, such as medication administration and nursing care. Nursing implications include increased attention to the role of sleep to promote intensive care unit patient's health outcomes and using multicomponent sleep-promoting protocols.

Precision health: A nursing perspective.

Precision health refers to personalized healthcare based on a person's unique genetic, genomic, or omic composition within the context of lifestyle, social, economic, cultural and environmental influences to help individuals achieve well-being and optimal health. Precision health utilizes big data sets that combine omics (i.e. genomic sequence, protein, metabolite, and microbiome information) with clinical information and health outcomes to optimize disease diagnosis, treatment and prevention specific to each patient. Successful implementation of precision health requires interprofessional collaboration, community outreach efforts, and coordination of care, a mission that nurses are well-positioned to lead. Despite the surge of interest and attention to precision health, most nurses are not well-versed in precision health or its implications for the nursing profession. Based on a critical analysis of literature and expert opinions, this paper provides an overview of precision health and the importance of engaging the nursing profession for its implementation. Other topics reviewed in this paper include big data and omics, information science, integration of family health history in precision health, and nursing omics research in symptom science. The paper concludes with recommendations for nurse leaders in research, education, clinical practice, nursing administration and policy settings for which to develop strategic plans to implement precision health.

Critical Update on the Third Edition of the Guidelines for Managing Severe Traumatic Brain Injury in Children.

BACKGROUND: Severe traumatic brain injury (TBI) is associated with high rates of death and disability. As a result, the revised guidelines for the management of pediatric severe TBI address some of the previous gaps in pediatric TBI evidence and management strategies targeted to promote overall health outcomes. OBJECTIVES: To provide highlights of the most important updates featured in the third edition of the guidelines for the management of pediatric severe TBI. These highlights can help critical care providers apply the most current and appropriate therapies for children with severe TBI. METHODS AND RESULTS: After a brief overview of the process behind identifying the evidence to support the third edition guidelines, both relevant and new recommendations from the guidelines are outlined to provide critical care providers with the most current management approaches needed for children with severe TBI. Recommendations for neuroimaging, hyperosmolar therapy, analgesics and sedatives, seizure prophylaxis, ventilation therapies, temperature control/hypothermia, nutrition, and corticosteroids are provided. In addition, the complete guideline document and its accompanying algorithm for recommended therapies are available electronically and are referenced within this article. CONCLUSIONS: The evidence base for treating pediatric TBI is increasing and provides the basis for high-quality care. This article provides critical care providers with a quick reference to the current evidence when caring for a child with a severe TBI. In addition, it provides direct access links to the comprehensive guideline document and algorithms developed to support critical care providers.