Readiness of emergency departments for pediatric patients and pediatric mortality: a systematic review.

BACKGROUND: Most children who need emergency care visit general emergency departments and urgent care centres; the weighted pediatric readiness score (WPRS) is currently used to evaluate emergency departments' readiness for pediatric patients. The aim of this study was to determine whether a higher WPRS was associated with decreased mortality and improved health care outcomes and utilization. METHODS: We conducted a systematic review of cohort and cross-sectional studies on emergency departments that care for children (age ≤ 21 yr). We searched MEDLINE (Ovid), Embase (Ovid), the Cochrane Library (Wiley), CINAHL (EBSCO), Global Health (Ovid) and Scopus from inception until July 29, 2022. Articles identified were screened for inclusion by 2 independent reviewers. The primary outcome was mortality, and the secondary outcomes were health care outcomes and utilization. We used the Newcastle-Ottawa Scale to assess for quality and bias of the included studies. The I 2 statistic was calculated to quantify study heterogeneity. RESULTS: We identified 1789 articles. Eight articles were included in the final analysis. Three studies showed an inverse association between highest WPRS quartile and pediatric mortality (pooled odds ratio [OR] 0.45, 95% confidence interval [CI] 0.26 to 0.78; I 2 = 89%, low certainty of evidence) in random-effects meta-analysis. Likewise, 1 study not included in the meta-analysis also reported an inverse association with a 1-point increase in WPRS (OR 0.93, 95% CI 0.88 to 0.98). One study reported that the highest WPRS quartile was associated with shorter length of stay in hospital (ß -0.36 days, 95% CI -0.61 to -0.10). Three studies concluded that the highest WPRS quartile was associated with fewer interfacility transfers. The certainty of evidence is low for mortality and moderate for the studied health care outcomes and utilization. INTERPRETATION: The data suggest a potential inverse association between the WPRS of emergency departments and mortality risk in children. More studies are needed to refute or confirm these findings. PROTOCOL REGISTRATION: PROSPERO-CRD42020191149.

Interpersonal attribution bias and social evaluation in adolescent eating disorders.

OBJECTIVE: Improved understanding of adolescent eating disorders (EDs), including identification and refinement of treatment and recovery targets, may help improve clinical outcomes. Interpersonal function is a proposed risk and maintenance factor that may be particularly relevant given the significance of adolescence for both psychosocial development and ED onset. This study examined self-referential thinking in adolescents with EDs compared to healthy adolescents. METHOD: Twenty-nine adolescents with EDs and 31 healthy controls completed a self-report measure of interpersonal attributions as well as a verbal appraisal task that required conducting direct and indirect evaluations about oneself and direct evaluations about others. RESULTS: The ED group had a more negative self-attribution bias than the control group (p = 0.006) even when controlling for depression severity. Additionally, the ED group exhibited less positive direct self (p < 0.001), direct social (p = 0.015), and social reflected self-appraisals (p = 0.011) than the healthy cohort. After including depression as a covariate in the verbal appraisal model, the model was no longer significant, suggesting group differences related to social appraisals may be mediated by depression. CONCLUSIONS: Adolescents with EDs have more negative interpersonal beliefs than comparison adolescents. Future studies are needed to determine how the constructs identified here relate to clinical course.

Qualitative patient experiences from the Self-Blame and Perspective-Taking Intervention for eating disorders.

BACKGROUND: Problems in social cognition and social support contribute to eating disorders (ED). Group therapy provides an ideal format to create an experiential learning environment focused on understanding social interactions. This pilot study examined the qualitative content of the participants' experiences in the Self-Blame and Perspective-Taking Intervention (SBPI) for ED. METHODS: The SBPI was a 4-week group therapy intervention involving art therapy and psychoeducation that focused on social behaviors in ED patients. Participants received surveys immediately after the intervention and at 1 to 4 weeks after the post-intervention. Thematic analyses of qualitative feedback were performed using Braun and Clarke's thematic analysis framework. RESULTS: Inductive analyses revealed three main themes: (1) Developing self-acceptance through emotional reflection, (2) Changing expectations with neurosocial knowledge, and (3) Bonding and vulnerability in social interactions; all concepts intentionally targeted by the SBPI. Participants varied in their support of a guideline to exclude personal discussion of ED-related cognitions and behaviors in the group. CONCLUSIONS: As a whole, patients valued the combination of psychosocial education with group experientials focused on social behavior. Positive feedback from the SBPI suggests that adjunctive treatments that target mental-wellness constructs indirectly related to ED pathology may be helpful by allowing patients to see themselves as separable from the illness. Trial registration ClinicalTrials.gov, NCT0487758. Registered 7 May 2021-Retrospectively registered. https://clinicaltrials.gov/ct2/show/NCT04877158 .

Adult patients with eating disorders frequently report challenges in developing and maintaining supportive social relationships. A group therapy intervention utilizing structured art tasks in conjunction with psychoeducation about interpersonal relationships was piloted in twenty-four women with eating disorders. Participants provided written feedback about their experiences in the intervention. These responses were coded by three raters to identify consistent themes related to those experiences. Participants reported benefits related to self-acceptance and emotional regulation, valued learning about their brain and behaviors, and appreciated peer interactions in this setting. In sum, this adjunctive and structured outpatient group targeting social interactions was acceptable to outpatients with eating disorders.

Pilot data from the Self-Blame and Perspective-Taking Intervention for eating disorders.

Eating disorders (EDs) are characterized by altered eating behaviors and valuation of self-image, as well as difficulty establishing supportive social relationships. This pilot study evaluated feasibility, acceptability, and clinical responses to a novel and brief group-therapy intervention for EDs, the Self-Blame and Perspective-Taking Intervention (SBPI). The SBPI consisted of four sessions of experiential art therapy activities in conjunction with psychoeducation targeting interpersonal attributions and mentalization. Twenty-four outpatient, treatment-seeking women with EDs participated in the SBPI, with 87.5% completing the intervention and 94% rating their participation positively. ED symptoms, depression, anxiety, self-attribution bias, and self-esteem were assessed before (T1) and after participation (N = 20 at T2; N = 18 at T3). Separate repeated measures MANOVAs were performed to assess these clinical and self-concept variables. Relative to baseline, participants demonstrated significant improvements in two all self-concept measures: self-attribution bias, trait self-esteem and state self-esteem at T2. ED, depression, and anxiety symptoms were significantly decreased at both T2 (1-4 weeks post) and T3 (3-5 months post). The SBPI altered self-concept targets acutely and led to sustained clinical improvements. Future work is needed to evaluate how self-concept and social constructs are related to clinical symptom expression in EDs.

Characteristics of vomiting as a predictor of intracranial injury in pediatric minor head injury.

OBJECTIVES: Vomiting is common in children after minor head injury. In previous research, isolated vomiting was not a significant predictor of intracranial injury after minor head injury; however, the significance of recurrent vomiting is unclear. This study aimed to determine the value of recurrent vomiting in predicting intracranial injury after pediatric minor head injury. METHODS: This secondary analysis of the CATCH2 prospective multicenter cohort study included participants (0-16 years) who presented to a pediatric emergency department (ED) within 24 hours of a minor head injury. ED physicians completed standardized clinical assessments. Recurrent vomiting was defined as ≥ four episodes. Intracranial injury was defined as acute intracranial injury on computed tomography scan. Predictors were examined using chi-squared tests and logistic regression models. RESULTS: A total of 855 (21.1%) of the 4,054 CATCH2 participants had recurrent vomiting, 197 (4.9%) had intracranial injury, and 23 (0.6%) required neurosurgical intervention. Children with recurrent vomiting were significantly more likely to have intracranial injury (odds ratio [OR], 2.3; 95% confidence interval [CI], 1.7-3.1), and require neurosurgical intervention (OR, 3.5; 95% CI, 1.5-7.9). Recurrent vomiting remained a significant predictor of intracranial injury (OR, 2.8; 95% CI, 1.9-3.9) when controlling for other CATCH2 criteria. The probability of intracranial injury increased with number of vomiting episodes, especially when accompanied by other high-risk factors, including signs of a skull fracture, or irritability and Glasgow Coma Scale score < 15 at 2 hours postinjury. Timing of first vomiting episode, and age were not significant predictors. CONCLUSIONS: Recurrent vomiting (≥ four episodes) was a significant risk factor for intracranial injury in children after minor head injury. The probability of intracranial injury increased with the number of vomiting episodes and if accompanied by other high-risk factors, such as signs of a skull fracture or altered level of consciousness.

Treatment Utilization and Medical Problems in a Community Sample of Adult Women With Anorexia Nervosa.

Anorexia nervosa (AN) has a prolonged course of illness, making both defining recovery and determining optimal outpatient treatments difficult. Here, we report the types of treatments utilized in a naturalistic sample of adult women with AN in Texas. Participants were recruited from earlier studies of women with AN (n = 28) and in weight recovery following AN (n = 18). Participants provided information about both their illness and treatments during their most severe period as well as during the 2-6 years following original assessments. Based upon their baseline and follow-up clinical status participants were classified as remaining ill (AN-CC, n = 17), newly in recovery (AN-CR, n = 11), and sustained weight-recovery (AN-WR, n = 18). Utilization of health care institutions and providers were compared across groups. There were no differences in groups related to symptoms or treatments utilized during the severe-period. During the follow-up period, intensive outpatient programs were utilized significantly more by the AN-CC group than the other groups, and dietitians were seen significantly less by the AN-WR group. Medical complications related to the ED were significantly more common in the AN-CC group. All groups maintained similar levels of contact with outpatient psychiatrists, therapists, and primary care physicians. Current treatments remain ineffective for a subset of AN participants. Future prospective studies assessing medical health and comorbidities in AN may provide additional insights into disease severity and predictors of clinical outcome.

Mentalization and the left inferior frontal gyrus and insula.

OBJECTIVE: To determine if an interpersonal attribution bias associated with self-perception, the externalizing bias, was related to neural activations during mentalization. METHODS: A functional magnetic resonance imaging task involving verbal appraisals measured neural activations when thinking about oneself and others in 59 adults, including healthy women as well as women with and recovered from anorexia nervosa. Whole-brain regressions correlated brain function during mentalization with the externalizing bias measured using the Internal, Personal, and Situational Attributions Questionnaire. RESULTS: Women with anorexia nervosa had a lower externalizing bias, demonstrating a tendency to self-attribute more negative than positive social interactions, unlike the other groups. The externalizing bias was correlated with activation of the left inferior frontal gyrus and posterior insula, when comparing thinking about others evaluating oneself with direct self-evaluation. DISCUSSION: Externalizing biases may provide an office-based assay reflecting neurocognitive disturbances in social self-perception that are common during anorexia nervosa.

Pilot investigation into the sickness response to influenza vaccination in adults: Effect of depression and anxiety.

OBJECTIVE: To determine whether depressed or anxious patients experience greater affective change than mentally healthy individuals following influenza vaccination. METHODS: Participants (n=112) completed the Positive and Negative Affect Schedule (PANAS) before influenza vaccination and 1-2days post-vaccination (M=32.3h). Pre- and post-vaccination PANAS scores were compared using two-tailed, paired-samples t-tests. Change in positive affect between participants with depression or anxiety and those without was compared using two-way ANOVA. Follow up positive affect was further examined using multiple linear regression. RESULTS: Positive affect decreased following vaccination (M=2.18, 95% CI [1.07, 3.29], t(111)=3.89, p<0.001) for all participants and was more pronounced for those with anxiety or depression (F(1, 110)=7.51, p=0.009). Similarly, predicted follow up affect score was higher for those without a mental health conditions (ß=3.67, 95% CI [1.18, 6.16], t(103)=2.92, p=0.004). CONCLUSIONS: These data suggest that influenza vaccine has a greater effect on affect in patients with depression and anxiety than in mentally healthy individuals. This effect was focused on positive affect, suggesting that influenza vaccine induced inflammation may be best suited to examine alterations in positive affect and positive valence systems.

Neuropsychological and Cognitive Correlates of Recovery in Anorexia Nervosa.

OBJECTIVE: To identify clinical or cognitive measures either predictive of illness trajectory or altered with sustained weight recovery in adult women with anorexia nervosa. METHODS: Participants were recruited from prior studies of women with anorexia nervosa (AN-C) and in weight-recovery following anorexia nervosa (AN-WR). Participants completed a neuropsychological battery at baseline and clinical assessments at both baseline and follow-up. Groups based on clinical outcome (continued eating disorder, AN-CC; newly in recovery, AN-CR; sustained weight-recovery, AN-WR) were compared by using one-way ANOVAs with Bonferroni-corrected post hoc comparisons. RESULTS: Women with continued eating disorder had poorer neuropsychological function and self-competence at baseline than AN-CR. AN-CR showed changes in depression and externalizing bias, a measure of self-related attributions. AN-WR differed from both AN-CC and AN-CR at baseline in externalizing bias, but only from AN-CC at outcome. DISCUSSION: Neuropsychological function when recently ill may be a prognostic factor, while externalizing bias may provide a clinical target for recovery. Copyright © 2017 John Wiley & Sons, Ltd and Eating Disorders Association.

Neural activations are related to body-shape, anxiety, and outcomes in adolescent anorexia nervosa.

Anorexia nervosa (AN) is an illness that frequently begins during adolescence and involves weight loss. Two groups of adolescent girls (AN-A, weight-recovered following AN) and (HC-A, healthy comparison) completed a functional magnetic resonance imaging task involving social evaluations, allowing comparison of neural activations during self-evaluations, friend-evaluations, and perspective-taking self-evaluations. Although the two groups were not different in their whole-brain activations, anxiety and body shape concerns were correlated with neural activity in a priori regions of interest. A cluster in medial prefrontal cortex and the dorsal anterior cingulate correlated with the body shape questionnaire; subjects with more body shape concerns used this area less during self than friend evaluations. A cluster in medial prefrontal cortex and the cingulate also correlated with anxiety such that more anxiety was associated with engagement when disagreeing rather than agreeing with social terms during self-evaluations. This data suggests that differences in the utilization of frontal brain regions during social evaluations may contribute to both anxiety and body shape concerns in adolescents with AN. Clinical follow-up was obtained, allowing exploration of whether brain function early in course of disease relates to illness trajectory. The adolescents successful in recovery used the posterior cingulate and precuneus more for friend than self evaluations than the adolescents that remained ill, suggesting that neural differences related to social evaluations may provide clinical predictive value. Utilization of both MPFC and the precuneus during social and self evaluations may be a key biological component for achieving sustained weight-recovery in adolescents with AN.

A Balanced Protocol for Return to School for Children and Youth Following Concussive Injury.

BACKGROUND: Few protocols exist for returning children/youth to school after concussion. Childhood concussion can significantly affect school performance, which is vital to social development, academic learning, and preparation for future roles. The goal of this knowledge translation research was to develop evidence based materials to inform physicians about pediatric concussion. METHODS: The Return to School (RTS) concussion protocol was developed following the National Institute for Health and Care Excellence procedures. RESULTS: Based on a scoping review, and stakeholder opinions, an RTS protocol was developed for children/youth. This unique protocol focuses on school adaptation in 4 main areas: (a) timetable/attendance, (b) curriculum, (c) environmental modifications, and (d) activity modifications. CONCLUSION: A balance of cognitive rest and timely return to school need to be considered for returning any student to school after a concussion. Implementation of these new recommendations may be an important tool in prevention of prolonged absence from school and academic failure while supporting brain recovery.

Development of a conservative protocol to return children and youth to activity following concussive injury.

BACKGROUND: Consensus-based guidelines exist for adult athletes returning to play after concussion, but there are no protocols developed specifically for children. The goal of this knowledge translation research was to develop evidence-based materials to inform physicians about pediatric concussion. METHODS: A pediatric concussion protocol was developed based on the National Institute for Health and Care Excellence procedures. RESULTS: This return to activity protocol was developed to guide management when children/youth sustain a concussion. The protocol incorporated 3 main themes: (a) a protocol must include return to all activity, including sport and school; (b) existing consensus-based adult protocols are not appropriate for children; and (c) a more conservative protocol is needed. After pilot testing, the developed protocol is being used across Ontario. CONCLUSION: Implementation of these new pediatric recommendations is an important addition to prevention of subsequent concussions during vulnerable recovery periods, with potential to facilitate recovery by preventing prolonged symptomatology, and secondary sequelae.

'Wondering and waiting' after obstetrical brachial plexus injury: Are we underestimating the effects of the traumatic experience on the families?

BACKGROUND: Obstetrical brachial plexus injury (OBPI) in children can cause great distress to a family due to uncertain recovery, variability in spontaneous recovery and unclear indicators for surgery. OBJECTIVE: To investigate the impact of having a child with OBPI on the family and whether the Impact on Family Scale (IoFS) can assist in addressing family concerns. METHODS: A mixed-method (cross-sectional survey and semistructured interviews) study design was used. RESULTS: Thirty-eight families of children with OBPI completed the IoFS. Surgery significantly predicted a higher IoFS total impact score (P=0.02). No statistically significant association between the total impact score and severity or age was found, suggesting that impact on family was not dependent on these factors. Themes that emerged from the interviews included traumatic birthing experience, wondering and waiting, and experiencing surgery. CONCLUSION: All families should receive support and acknowledgement of the widespread impact of OBPI.

HISTORIQUE: La lésion obstétricale du plexus brachial (LOPB) chez les enfants peut susciter une grande détresse dans une famille en raison de l'incertitude quant au rétablissement, de la variabilité du rétablissement spontané et du caractère flou des indicateurs de chirurgie. OBJECTIF: Examiner les répercussions d'un enfant ayant une LOPB sur la famille et si l'échelle IoFS des répercussions sur les membres de la famille peut contribuer à répondre à leurs inquiétudes. MÉTHODOLOGIE: Une méthodologie mixte (étude transversale et entrevues semi-structurées) a été privilégiée. RÉSULTATS: Trente-huit familles d'enfants ayant une LOPB ont rempli l'échelle IoFS. La chirurgie prédisait de manière significative un indice d'IoFS total plus élevé (P=0,02). L'association entre l'indice total et la gravité ou l'âge n'était pas significative. Les répercussions sur la famille ne dépendraient donc pas de ces facteurs. Les thèmes qui ont émergé des entrevues incluaient une expérience d'accouchement traumatisante, de l'inquiétude et de l'attente et l'expérience de la chirurgie. CONCLUSION: Toutes les familles devraient recevoir du soutien, et les effets généralisés de la LOPB sur leur état devraient être pris en compte.

Cognitive and language outcomes in HIV-uninfected infants exposed to combined antiretroviral therapy in utero and through extended breast-feeding.

OBJECTIVE: To determine whether there is a higher risk for cognitive or language delay among HIV-exposed uninfected (HEU) children exposed to cART (zidovudine/lamivudine/lopinavir/ritonavir) in utero and through 1 year of breast-feeding (World health Organization Option B+), compared with the control children born to HIV-uninfected mothers. DESIGN: This is a double cohort study from Lusaka, Zambia. METHODS: HEU (n = 97) and control (n = 103) children aged 15-36 months were assessed on their early nonverbal problem-solving and language skills using the standardized Capute Scales. A score of less than 85 on the Capute Full-Scale Developmental Quotient (FSDQ) was considered indicative of developmental delay and was the primary outcome of interest. RESULTS: An FSDQ of less than 85 was found in eight (8.3%) of HEU participants and 15 (14.6%) of controls. In univariate logistic regressions, lower income [odds ratio (OR) = 0.93, P = 0.02], older infant age (OR = 1.08, P = 0.03), lower birth weight (OR = 0.16, P < 0.001), and less maternal education (OR = 0.41, P = 0.047) were associated with the probability of FSDQ less than 85, whereas Group (control/HEU) was not (OR = 1.88, P = 0.16). In the multivariable analysis, only lower birth weight (OR = 0.15, P < 0.001) remained associated with FSDQ less than 85. CONCLUSIONS: Our study did not support the presence of an adverse effect on cognitive and language development with prolonged antepartum and postpartum cART e/xposure. Larger studies and studies of older HEU children will be required to confirm these reassuring findings.

Evaluating the Nintendo Wii for assessing return to activity readiness in youth with mild traumatic brain injury.

Adolescents with mild traumatic brain injuries (MTBI) are at substantial risk for repeat injury if they return to activity too soon. Post-concussion symptoms and impaired balance are two factors that limit return to activity. Post-injury assessments that challenge activity tolerance and balance skills are needed to ensure readiness to return to activity. This cross-sectional study evaluated the Nintendo Wii as a measure of exertion (heart rate [HR], respiration rate [RR], and caloric expenditure) and balance testing for youth with MTBI in a clinical setting. Twenty-four youth with MTBI, ages 9-18, played six Wii games. The Bruininks-Oseretsky Test of Motor Proficiency 2nd edition (BOT-2) and the Community Balance and Mobility Scale (CBM) were used as balance indicators. The Wii Fit Running game demonstrated the highest caloric expenditure and HR (p = .010). Frequency counts of balance loss during Wii game play did not correlate with performance on the BOT-2 or the CBM. Type, number, and time since injury were predictive of balance performance on the CBM (p = .008). Findings provide preliminary evidence for the use of the Wii as an exertion challenge to evaluate tolerance for exercise post-concussion. Frequency count of balance loss during Wii game play, however, was not a valid measure of balance impairment post-MTBI.

Limb length differences after obstetrical brachial plexus injury: a growing concern.

BACKGROUND: Residual size discrepancy between the affected and unaffected limbs is a distinct but not well-understood consequence of an obstetrical brachial plexus injury. This study aimed to document the extent of limb length differences in children with obstetrical brachial plexus injury compared with typically developing children. The effects of age, growth patterns, severity, and surgical intervention were also explored. Also, this study examined the reliability of the clinical measurement technique. METHODS: A prospective cohort of 179 children with obstetrical brachial plexus injury was systematically evaluated for limb length and girth by a multidisciplinary team. Clinical measurements were obtained at regular intervals until 12 months and then yearly. A control group of typically developing children aged 6 months to 17 years had limb length and girth measured on one occasion. RESULTS: Interrater reliability of clinical measurement techniques demonstrated high consistency, with an intraclass correlation of 0.90 (p < 0.0001). Limb measurements were recorded at nine time points. Paired t tests of children with and without surgical intervention found significant differences between affected and unaffected sides in arm, forearm, and total length as early as the 1-month measurement and at most other time points (p < 0.05). The 3-month total limb length difference was a statistically significant predictor of 12-month limb length difference (p < 0.05). CONCLUSIONS: Obstetrical brachial plexus injury significantly affects the length of the arm and forearm. Early detectable limb length deficits are associated with the likelihood of requiring surgical reconstruction. Clinical limb length measurement can be performed reliably and noninvasively.