Nutrition Interventions for Lowering Cardiovascular Risk After Hypertensive Disorders of Pregnancy: A Systematic Review.

Background: Hypertension is one of the most common medical problems during pregnancy. Hypertensive disorders of pregnancy (HDP) increase the risk of premature cardiovascular disease (CVD) 2- to 4-fold within 10 years after delivery. Early health behaviour modifications may prevent or manage several cardiovascular risk factors. Importantly, compared with women without HDP, fewer women with HDP achieve national dietary guidelines to prevent CVD. This highlights an opportunity for programs tailored for women post-HDP to support their nutritional behaviours as a key component of postpartum CVD preventive care. This systematic review investigated the impacts of nutrition modifications on lowering measures of CVD risk after HDP. Methods: Four electronic databases (MEDLINE, EMBASE, CINAHL, Cochrane Library) were searched in October 2022 with a search strategy focused on nutrition programs/interventions and women post-HDP. Additional inclusion criteria were original research and reported outcome of CVD risk or cardiovascular risk factors. Results: Six studies were included: 4 experimental trials and 2 prospective cohort studies. Of the nutrition interventions, 4 were embedded within comprehensive health behaviour intervention programs. Outcome measures varied, but all studies reported blood pressure. A narrative synthesis found that the range of changes in blood pressure varied from no change to clinically meaningful change. Conclusions: This review found statistically nonsignificant yet clinically important improvements in measures of cardiovascular risk across a range of nutritional interventions in women after HDP. Further high-quality evidence is needed to inform the design and implementation of nutritional preventive cardiovascular care targeting this high CVD-risk population.

Contexte: L'hypertension est l'un des problèmes médicaux les plus fréquents durant la grossesse. Les troubles hypertensifs de la grossesse (THG) font augmenter le risque de maladies cardiovasculaires (MCV) prématurées de 2 à 4 fois dans les 10 années après l'accouchement. Des modifications précoces des comportements liés à la santé peuvent permettre de prévenir ou de prendre en charge plusieurs facteurs de risque cardiovasculaire. Notamment, par rapport aux femmes sans THG, moins de femmes atteintes de THG se conforment aux lignes directrices nationales en matière d'alimentation pour prévenir les MCV. D'où la possibilité qui s'offre aux programmes adaptés aux femmes post-THG d'encourager l'adoption de leurs comportements nutritionnels, une composante essentielle des soins de prévention des MCV dans la période du post-partum. La présente revue systématique visait à examiner les répercussions des modifications nutritionnelles sur la réduction des mesures du risque de MCV après les THG. Méthodes: En octobre 2022, nous avons effectué des recherches dans 4 bases de données électroniques (MEDLINE, Embase, CINAHL, Cochrane Library) au moyen d'une stratégie de recherche axée sur les interventions/programmes nutritionnels et les femmes post-THG. Les critères d'inclusion supplémentaires étaient la recherche initiale et les résultats signalés du risque de MCV ou des facteurs de risque cardiovasculaire. Résultats: Nous avons tenu compte de 6 études : 4 essais expérimentaux et 2 études de cohorte prospectives. Parmi les interventions nutritionnelles, 4 étaient intégrées aux programmes exhaustifs d'interventions sur les comportements liés à la santé. Les critères de jugement variaient, mais la pression artérielle était signalée dans toutes les études. Une synthèse narrative a permis de constater que l'étendue des changements dans la pression artérielle allait d'une absence de changement à des changements significatifs sur le plan clinique. Conclusions: Cette revue a permis de constater des améliorations non significatives sur le plan statistique, mais importantes sur le plan clinique des mesures du risque cardiovasculaire de différentes interventions nutritionnelles chez les femmes après les THG. D'autres données probantes de grande qualité sont nécessaires pour faciliter l'élaboration et la mise en œuvre de soins de prévention nutritionnelle des maladies cardiovasculaires visant cette population exposée à un risque élevé de MCV.

Pediatric Death After Withdrawal of Life-Sustaining Therapies: A Scoping Review.

OBJECTIVES: Evaluate literature on the dying process in children after withdrawal of life sustaining measures (WLSM) in the PICU. We focused on the physiology of dying, prediction of time to death, impact of time to death, and uncertainty of the dying process on families, healthcare workers, and organ donation. DATA SOURCES: MEDLINE, Embase, Cochrane Central Register of Controlled Trials, PsycINFO, CINAHL, and Web of Science. STUDY SELECTION: We included studies that discussed the dying process after WLSM in the PICU, with no date or study type restrictions. We excluded studies focused exclusively on adult or neonatal populations, children outside the PICU, or on organ donation or adult/pediatric studies where pediatric data could not be isolated. DATA EXTRACTION: Inductive qualitative content analysis was performed. DATA SYNTHESIS: Six thousand two hundred twenty-five studies were screened and 24 included. Results were grouped into four categories: dying process, perspectives of healthcare professionals and family, WLSM and organ donation, and recommendations for future research. Few tools exist to predict time to death after WLSM in children. Most deaths after WLSM occur within 1 hour and during this process, healthcare providers must offer support to families regarding logistics, medications, and expectations. Providers describe the unpredictability of the dying process as emotionally challenging and stressful for family members and staff; however, no reports of families discussing the impact of time to death prediction were found. The unpredictability of death after WLSM makes families less likely to pursue donation. Future research priorities include developing death prediction tools of tools, provider and parental decision-making, and interventions to improve end-of-life care. CONCLUSIONS: The dying process in children is poorly understood and understudied. This knowledge gap leaves families in a vulnerable position and the clinical team without the necessary tools to support patients, families, or themselves. Improving time to death prediction after WLSM may improve care provision and enable identification of potential organ donors.

Small for gestational age preterm infants and later adiposity and height: A systematic review and meta-analysis.

BACKGROUND: Overweight and obesity and their consequent morbidities are important worldwide health problems. Some research suggests excess adiposity origins may begin in fetal life, but unknown is whether this applies to infants born preterm. OBJECTIVE: The objective of the study was to assess the association between small for gestational age (SGA) birth and later adiposity and height among those born preterm. DATA SOURCES: MEDLINE, EMBASE and CINAHL until October 2022. STUDY SELECTION AND DATA EXTRACTION: Studies were included if they reported anthropometric (adiposity measures and height) outcomes for participants born preterm with SGA versus non-SGA. Screening, data extraction and risks of bias assessments were conducted in duplicate by two reviewers. SYNTHESIS: We meta-analysed across studies using random-effects models and explored potential heterogeneity sources. RESULTS: Thirty-nine studies met the inclusion criteria. In later life, preterm SGA infants had a lower body mass index (-0.66 kg/m2 , 95% CI -0.79, -0.53; 32 studies, I2 = 16.7, n = 30,346), waist circumference (-1.20 cm, 95% CI -2.17, -0.23; 13 studies, I2 = 19.4, n = 2061), lean mass (-2.62 kg, 95% CI -3.45, 1.80; 7 studies, I2 = 0, n = 205) and height (-3.85 cm, 95% CI -4.73, -2.96; 26 studies, I2 = 52.6, n = 4174) compared with those preterm infants born non-SGA. There were no differences between preterm SGA and preterm non-SGA groups in waist/hip ratio, body fat, body fat per cent, truncal fat per cent, fat mass index or lean mass index, although power was limited for some analyses. Studies were rated at high risk of bias due to potential residual confounding and low risk of bias in other domains. CONCLUSIONS: Compared to their preterm non-SGA peers, preterm infants born SGA have lower BMI, waist circumference, lean body mass and height in later life. No differences in adiposity were observed between SGA preterm infants and non-SGA preterm infants.

A Scoping Review on the Use of Experiential Learning in Professional Education on Intimate Partner Violence.

Purpose: Intimate partner violence (IPV) involves any form of emotional, physical, and sexual abuse including controlling behaviors by an intimate partner. Front line service workers such as social workers, nurses, lawyers, and physicians are often the first professionals to come into contact with individuals experiencing IPV but are often inadequately prepared to respond appropriately as IPV education is highly variable. Experiential learning (EL), also known as learning by doing, has gained much attention from educators; however, the extent and type of EL strategies used to teach IPV competencies has not yet been explored. Our aim was to extract what is known from the literature about the use of EL strategies to teach IPV competencies to front line service providers. Methods: We conducted a search from May 2021 through November 2021. Reviewers independently screened citations in duplicate using pre-determined eligibility criteria. Data collected included study demographics (publication year, country, etc.), study participants, and information about the IPV EL. Results: Of 5216 identified studies, 61 were included. Medicine and nursing represented the majority of learners in the included literature. Graduate students were the targeted learners in 48% of articles. Low fidelity EL was used most frequently in 48% of the articles; and role play was the EL mode most frequently utilized (39%) overall. Conclusions: This scoping review provides a comprehensive overview of the limited literature on how EL is used to teach IPV competencies and identifies significant gaps related to the lack of intersectional analysis within educational interventions. Supplementary Information: The online version contains supplementary material available at 10.1007/s10896-023-00552-4.

Brain-based arterial pulse pressure threshold for death determination: a systematic review.

PURPOSE: There is lack of consensus regarding the minimum arterial pulse pressure required for confirming permanent cessation of circulation for death determination by circulatory criteria in organ donors. We assessed direct and indirect evidence supporting whether one should use an arterial pulse pressure of 0 mm Hg vs more than 0 (5, 10, 20, 40) mm Hg to confirm permanent cessation of circulation. SOURCE: We conducted this systematic review as part of a larger project to develop a clinical practice guideline for death determination by circulatory or neurologic criteria. We systematically searched Ovid MEDLINE, Ovid Embase, Cochrane Central Register of Controlled Trials (CENTRAL) via the Cochrane Library, and Web of Science for articles published from inception until August 2021. We included all types of peer-reviewed original research publications related to arterial pulse pressure as monitored by an indwelling arterial pressure transducer around circulatory arrest or determination of death with either direct context-specific (organ donation) or indirect (outside of organ donation context) data. PRINCIPAL FINDINGS: A total of 3,289 abstracts were identified and screened for eligibility. Fourteen studies were included; three from personal libraries. Five studies were of sufficient quality for inclusion in the evidence profile for the clinical practice guideline. One study measured cessation of cortical scalp electroencephalogram (EEG) activity after withdrawal of life-sustaining measures and showed that EEG activity fell below 2 µV when the pulse pressure reached 8 mm Hg. This indirect evidence suggests there is a possibility of persistent cerebral activity at arterial pulse pressures > 5 mm Hg. CONCLUSION: Indirect evidence suggests that clinicians may incorrectly diagnose death by circulatory criteria if they apply any arterial pulse pressure threshold of greater than 5 mm Hg. Moreover, there is insufficient evidence to determine that any pulse pressure threshold greater than 0 and less than 5 can safely determine circulatory death. STUDY REGISTRATION: PROSPERO (CRD42021275763); first submitted 28 August 2021.

RéSUMé: OBJECTIF: Il n'y a pas de consensus concernant la pression artérielle minimale requise pour confirmer l'arrêt permanent de la circulation pour la détermination du décès selon des critères circulatoires chez les donneurs d'organes. Nous avons évalué les données probantes directes et indirectes soutenant l'utilisation d'une pression pulsée artérielle de 0 mmHg vs plus de 0 (5, 10, 20, 40) mm Hg pour confirmer l'arrêt définitif de la circulation. SOURCES: Nous avons réalisé cette revue systématique dans le cadre d'un projet plus vaste visant à élaborer des lignes directrices de pratique clinique pour la détermination du décès selon des critères circulatoires ou neurologiques. Nous avons mené des recherches systématiques dans Ovid MEDLINE, Ovid Embase, le registre Cochrane des études contrôlées (CENTRAL) via la Cochrane Library et Web of Science pour trouver des articles publiés depuis leur création jusqu'en août 2021. Nous avons inclus tous les types de publications de recherches originales évaluées par des pairs liées à la pression pulsée artérielle telle que surveillée par un transducteur de pression artérielle à demeure entourant un arrêt circulatoire ou de une détermination de décès avec des données directes spécifiques au contexte (don d'organes) ou indirectes (en dehors d'un contexte du don d'organes). CONSTATATIONS PRINCIPALES: Au total, 3289 résumés ont été identifiés et examinés pour déterminer leur admissibilité. Quatorze études ont été incluses, trois provenant de bibliothèques personnelles. Cinq études étaient de qualité suffisante pour être incluses dans le profil de données probantes des Lignes directrices de pratique clinique. Une étude a mesuré l'arrêt de l'activité de l'électroencéphalogramme (EEG) au niveau du scalp cortical après l'interruption des thérapies de maintien des fonctions vitales et a montré que l'activité EEG tombait en dessous de 2 µV lorsque la pression pulsée atteignait 8 mm Hg. Ces données probantes indirectes suggèrent qu'il existe une possibilité d'activité cérébrale persistante à des pressions pulsées artérielles > 5 mm Hg. CONCLUSION: Des données probantes indirectes suggèrent que les cliniciens pourraient diagnostiquer à tort un décès selon des critères circulatoires s'ils appliquent un seuil de pression pulsée artérielle supérieur à 5 mm Hg. De plus, il n'y a pas suffisamment de données probantes pour déterminer que tout seuil de pression pulsée supérieur à 0 et inférieur à 5 peut permettre de déterminer en toute sécurité un décès cardiocirculatoire. ENREGISTREMENT DE L'éTUDE: PROSPERO (CRD42021275763); soumis pour la première fois le 28 août 2021.

Autoresuscitation after circulatory arrest: an updated systematic review.

PURPOSE: Current practice in organ donation after death determination by circulatory criteria (DCD) advises a five-minute observation period following circulatory arrest, monitoring for unassisted resumption of spontaneous circulation (i.e., autoresuscitation). In light of newer data, the objective of this updated systematic review was to determine whether a five-minute observation time was still adequate for death determination by circulatory criteria. SOURCE: We searched four electronic databases from inception to 28 August 2021, for studies evaluating or describing autoresuscitation events after circulatory arrest. Citation screening and data abstraction were conducted independently and in duplicate. We assessed certainty in evidence using the GRADE framework. PRINCIPAL FINDINGS: Eighteen new studies on autoresuscitation were identified, consisting of 14 case reports and four observational studies. Most studies evaluated adults (n = 15, 83%) and patients with unsuccessful resuscitation following cardiac arrest (n = 11, 61%). Overall, autoresuscitation was reported to occur between one and 20 min after circulatory arrest. Among all eligible studies identified by our reviews (n = 73), seven observational studies were identified. In observational studies of controlled withdrawal of life-sustaining measures with or without DCD (n = 6), 19 autoresuscitation events were reported in 1,049 patients (incidence 1.8%; 95% confidence interval, 1.1 to 2.8). All resumptions occurred within five minutes of circulatory arrest and all patients with autoresuscitation died. CONCLUSION: A five-minute observation time is sufficient for controlled DCD (moderate certainty). An observation time greater than five minutes may be needed for uncontrolled DCD (low certainty). The findings of this systematic review will be incorporated into a Canadian guideline on death determination. STUDY REGISTRATION: PROSPERO (CRD42021257827); registered 9 July 2021.

RéSUMé: OBJECTIF: La pratique actuelle en matière de don d'organes après une détermination du décès par critères circulatoires (DCC) préconise une période d'observation de cinq minutes après l'arrêt circulatoire et le monitorage de la reprise non assistée de la circulation spontanée (c.-à-d. l'auto-réanimation). À la lumière de données plus récentes, l'objectif de cette revue systématique mise à jour était de déterminer si un temps d'observation de cinq minutes était toujours suffisant pour une détermination de décès selon des critères circulatoires (DCC). SOURCES: Nous avons effectué des recherches dans quatre bases de données électroniques depuis leur création jusqu'au 28 août 2021 pour en tirer les études évaluant ou décrivant des événements d'autoréanimation après un arrêt circulatoire. L'examen des citations et l'extraction des données ont été réalisés de manière indépendante et en double. Nous avons évalué la certitude des données probantes à l'aide de la méthodologie GRADE. CONSTATATIONS PRINCIPALES: Dix-huit nouvelles études sur l'autoréanimation ont été identifiées, comprenant 14 présentations de cas et quatre études observationnelles. La plupart des études ont évalué des adultes (n = 15, 83 %) et les patients dont la réanimation avait échoué à la suite d'un arrêt cardiaque (n = 11, 61 %). Dans l'ensemble, l'autoréanimation a été signalée entre une et 20 minutes après l'arrêt circulatoire. Parmi toutes les études admissibles identifiées par nos comptes rendus (n = 73), sept études observationnelles ont été identifiées. Dans les études observationnelles sur l'interruption contrôlée des thérapies de maintien des fonctions vitales avec ou sans DCC (n = 6), 19 événements d'autoréanimation ont été rapportés chez 1049 patients (incidence 1,8 % ; intervalle de confiance à 95 %, 1,1 à 2,8). Toutes les reprises ont eu lieu dans les cinq minutes suivant l'arrêt circulatoire et tous les patients en autoréanimation sont décédés. CONCLUSION: Un temps d'observation de cinq minutes est suffisant pour un DCC contrôlé (certitude modérée). Un temps d'observation supérieur à cinq minutes peut être nécessaire en cas de DDC non contrôlé (faible certitude). Les résultats de cette revue systématique seront intégrés à des lignes directrices canadienne de pratique clinique sur la détermination du décès. ENREGISTREMENT DE L'éTUDE: PROSPERO (CRD42021257827); enregistrée le 9 juillet 2021.

Unplanned Extubations Requiring Reintubation in Pediatric Critical Care: An Epidemiological Study.

OBJECTIVES: Unplanned extubations are an infrequent but life-threatening adverse event in pediatric critical care. Due to the rarity of these events, previous studies have been small, limiting the generalizability of findings and the ability to detect associations. Our objectives were to describe unplanned extubations and explore predictors of unplanned extubation requiring reintubation in PICUs. DESIGN: Retrospective observational study and multilevel regression model. SETTING: PICUs participating in Virtual Pediatric Systems (LLC). PATIENTS: Patients (≤ 18 yr) who had an unplanned extubation in PICU (2012-2020). INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: We developed and trained a multilevel least absolute shrinkage and selection operator (LASSO) logistic regression model in the 2012-2016 sample that accounted for between-PICU variations as a random effect to predict reintubation after unplanned extubation. The remaining sample (2017-2020) was used to externally validate the model. Predictors included age, weight, sex, primary diagnosis, admission type, and readmission status. Model calibration and discriminatory performance were evaluated using Hosmer-Lemeshow goodness-of-fit (HL-GOF) and area under the receiver operating characteristic curve (AUROC), respectively. Of the 5,703 patients included, 1,661 (29.1%) required reintubation. Variables associated with increased risk of reintubation were age (< 2 yr; odds ratio [OR], 1.5; 95% CI, 1.1-1.9) and diagnosis (respiratory; OR, 1.3; 95% CI, 1.1-1.6). Scheduled admission was associated with decreased risk of reintubation (OR, 0.7; 95% CI, 0.6-0.9). With LASSO (lambda = 0.011), remaining variables were age, weight, diagnosis, and scheduled admission. The predictors resulted in AUROC of 0.59 (95% CI, 0.57-0.61); HL-GOF showed the model was well calibrated (p = 0.88). The model performed similarly in external validation (AUROC, 0.58; 95% CI, 0.56-0.61). CONCLUSIONS: Predictors associated with increased risk of reintubation included age and respiratory primary diagnosis. Including clinical factors (e.g., oxygen and ventilatory requirements at the time of unplanned extubation) in the model may increase predictive ability.

Small for date preterm infants and risk of higher blood pressure in later life: A systematic review and meta-analysis.

BACKGROUND: Historical reports suggest that infants born small for gestational age (SGA) are at increased risk for high blood pressure (BP) at older ages after adjustment for later age body size. Such adjustment may be inappropriate since adiposity is a known cause of cardiovascular and metabolic disease. OBJECTIVES: To assess the association between SGA births and later BP among preterm births, considering potential background confounders and over-adjustment for later body size. METHODS: A database search of studies up to October 2022 included MEDLINE, EMBASE and CINAHL. Studies were included if they reported BP (systolic [SBP] or diastolic [DBP]) (outcomes) for participants born preterm with SGA (exposure) or non-SGA births. All screening, extraction steps, and risk of bias (using the Risk of Bias In Non-randomised Studies of Interventions [ROBINS-I] tool) were conducted in duplicate by two reviewers. Data were pooled in meta-analysis using random-effects models. We explored potential sources of heterogeneity. RESULTS: We found no meaningful difference in later BP between preterm infants with and without SGA status at birth. Meta-analysis of 25 studies showed that preterm SGA, compared to preterm non-SGA, was not associated with higher BP at age 2 and older with mean differences for SBP 0.01 mmHg (95% CI -0.10, 0.12, I2  = 59.8%, n = 20,462) and DBP 0.01 mm Hg (95% CI -0.10, 0.12), 22 studies, (I2  = 53.0%, n = 20,182). Adjustment for current weight did not alter the results, which could be due to the lack of differences in later weight status in most of the included studies. The included studies were rated to be at risk of bias due to potential residual confounding, with a low risk of bias in other domains. CONCLUSIONS: Evidence indicates that preterm infants born SGA are not at increased risk of developing higher BP as children or as adults as compared to non-SGA preterm infants.

"Walking on both sides of the fence": A qualitative exploration of the challenges and opportunities facing emergent clinician-scientists in child health.

RATIONALE, AIMS, AND OBJECTIVES: While paediatric clinician-scientists are ideally positioned to generate clinically relevant research and translate research evidence into practice, they face challenges in this dual role. The authors sought to explore the unique contributions, opportunities, and challenges of paediatric clinician-scientists, including issues related to training and ongoing support needs to ensure their success. METHOD: The authors used a qualitative descriptive approach with thematic analysis to explore the experiences of clinician-scientist stakeholders in child health (n = 39). Semi-structured interviews (60 min) were conducted virtually and recorded. Thematic analysis was conducted according to the phases outlined by Braun and Clarke (2006). RESULTS: The analysis resulted in the creation of three themes: (1) "Walking on both sides of the fence": unique positioning of clinician-scientists for advancing clinical practice and research; (2) the clinician-scientist: a specialized role with significant challenges; and (3) beyond the basics of clinical and research training programmes: essential skill sets and knowledge for future clinician-scientists. CONCLUSIONS: While clinician-scientists can make unique contributions to the advancement of evidence-based practice, they face significant barriers straddling their dual roles including divergent institutional cultures in healthcare and academia and a lack of infrastructure to effectively support clinician-scientist positions. Training programmes can play an important role in mentoring and supporting early-career clinician-scientists.

Quality improvement interventions to prevent unplanned extubations in pediatric critical care: a systematic review.

BACKGROUND: An unplanned extubation is the uncontrolled and accidental removal of a breathing tube and is an important quality indicator in pediatric critical care. The objective of this review was to comprehensively synthesize literature published on quality improvement (QI) practices implemented to reduce the rate of unplanned extubations in critically ill children. METHODS: We included original, primary research on quality improvement interventions to reduce the rate of unplanned extubations in pediatric critical care. A search was conducted in MEDLINE (Ovid), Embase, and CINAHL from inception through April 29, 2021. Two reviewers independently screened citations in duplicate using pre-determined eligibility criteria. Data from included studies were abstracted using a tool created by the authors, and QI interventions were categorized using the Behavior Change Wheel. Vote counting based on the direct of effect was used to describe the effectiveness of quality improvement interventions. Study quality was assessed using the Quality Improvement Minimum Quality Criteria Set (QI-MQCS). Results were presented as descriptive statistics and narrative syntheses. RESULTS: Thirteen studies were included in the final review. Eleven described primary QI projects; two were sustainability studies that followed up on previously described QI interventions. Under half of the included studies were rated as high-quality. The median number of QI interventions described by each study was 5 [IQR 4-5], with a focus on guidelines, environmental restructuring, education, training, and communication. Ten studies reported decreased unplanned extubation rates after the QI intervention; of these, seven had statistically significant reductions. Both sustainability studies observed increased rates that were not statistically significant. CONCLUSIONS: This review provides a comprehensive synthesis of QI interventions to reduce unplanned extubation. With only half the studies achieving a high-quality rating, there is room for improvement when conducting and reporting research in this area. Findings from this review can be used to support clinical recommendations to prevent unplanned extubations, and support patient safety in pediatric critical care. SYSTEMATIC REVIEW REGISTRATION: This review was registered on PROSPERO (CRD42021252233) prior to data extraction.

Equity, diversity and inclusion of pediatric clinician-scientists in Canada: a thematic analysis.

BACKGROUND: Underrepresented voices and perspectives are missing from academic and clinical health sciences. We aimed to define the unique opportunities and challenges of pediatric clinician-scientists related to equity, diversity and inclusion; and to identify key components of training needed to support people from equity-seeking groups as emerging and early-career pediatric clinician-scientists to generate diverse health research leaders in knowledge generation, implementation and translation. METHODS: Using a qualitative descriptive approach, we examined the experiences of clinician stakeholders. Semistructured interviews were conducted with pediatric clinician-scientist stakeholders. Thematic analysis was performed. RESULTS: We interviewed a total of 39 individuals. Our analysis resulted in 4 interrelated themes: the pervasiveness and invisibility of sexism; the invisibility and visibility of racism; proposed individual-level solutions to the sexism and racism; and proposed institutional and system-level changes to address the porous and leaky pipeline. These themes acknowledged that, ultimately, system change is required for addressing equity, diversity and inclusion in clinical and academic training environments. INTERPRETATION: These findings highlight the importance of addressing systemic biases that limit the inclusion of women and racialized individuals in pediatric clinician-scientist careers. Further research is needed to explore the problem of exclusion, which will, in turn, inform education of pediatric clinician-scientists and inform better ways to promote equity, diversity and inclusivity; these steps are needed to foster systemic change in the cultures that perpetuate exclusivity in both academic and clinical communities.

Curricula, Teaching Methods, and Success Metrics of Clinician-Scientist Training Programs: A Scoping Review.

PURPOSE: To describe the literature on clinician-scientist training programs to inform the development of contemporary and inclusive training models. METHOD: The authors conducted a scoping review, searching the PubMed/MEDLINE, CINAHL, and Embase databases from database inception until May 25, 2020. Studies presenting primary research that described and evaluated clinician-scientist training programs were identified for data abstraction. On the basis of deductive and inductive methods, information about program characteristics, curricula, teaching strategies, and success metrics was extracted. The extracted variables were analyzed using descriptive statistics. RESULTS: From the initial 7,544 citations retrieved and 4,974 unique abstracts screened, 81 studies were included. Of the 81 included studies, 65 (80.2%) were published between 2011 and 2020, 54 (66.7%) were conducted in the United States, and 64 (79.0%) described programs that provided broad clinician-scientist training. Few programs provided funding or protected research time or specifically addressed needs of trainees from underrepresented minority groups. Curricula emphasized research methods and knowledge dissemination, whereas patient-oriented research competencies were not described. Most programs incorporated aspects of mentorship and used multiple teaching strategies, such as direct and interactive instruction. Extrinsic metrics of success (e.g., research output) were dominant in reported program outcomes compared with markers of intrinsic success (e.g., career fulfillment). CONCLUSIONS: Although programs are providing clinician-scientists with practical skills training, opportunities exist for curricular and pedagogic optimization that may better support this complex career path. Training programs for clinician-scientists can address contemporary issues of wellness and equity by reconsidering metrics of program success and evolving the core tenets of their education models to include equity, diversity, and inclusion principles and patient-oriented research competencies.

Predicting prolonged length of stay in hospitalized children with respiratory syncytial virus.

BACKGROUND: Respiratory syncytial virus (RSV) is the most common cause of lower respiratory tract infections in children. This study aimed to predict the prolonged length of stay in children admitted to hospital with RSV. METHODS: Children aged <2 years with RSV in the National Inpatient Sample (NIS) were included in the analyses. The primary outcome was prolonged length of stay (≥90th percentile). Logistic regression models were developed using data from 2016; internal validation was completed using a bootstrapped sample. Data from 2017 were used to validate out-of-sample discrimination and calibration of the models. RESULTS: The sample included 9589 children; 1054 had prolonged length of stay (≥7 days). Children who were younger, transferred from another hospital, and required intubation during admission had a higher risk of prolonged length of stay. The prediction model included age, transport, intubation, comorbidities, hospital location, and teaching status. The area under the receiver operating characteristic curve was 0.73, demonstrating good predictive ability. The model performed similarly in external validation. CONCLUSIONS: Variables that predict the prolonged length of stay for RSV include younger age, transport, intubation, comorbidities, hospital location, and teaching status. This can be used to predict children who will have a prolonged length of stay when hospitalized for RSV. IMPACT: There are no recommended treatments for RSV; medical care involves supportive treatment such as oxygen delivery, hydration, and antipyretics. The clinical course is difficult to predict, partially attributable to the supportive nature of care and the sparsity of evidence-based therapies for this population. A prediction model was developed, demonstrating variables that predict prolonged length of stay in RSV hospitalizations, including age, interhospital transport, intubation, comorbidities, hospital location, and teaching status. The model was developed with a sample size of 9589 that is representative of all hospitalizations in the United States.

Comfort-holding in critically ill children: a scoping review.

PURPOSE: To understand and summarize the breadth of knowledge on comfort-holding in pediatric intensive care units (PICUs). SOURCES: This scoping review was conducted using PRISMA methodology. A literature search was conducted in MEDLINE, EMBASE, PsycINFO, CINAHL, and the Cochrane CENTRAL Register of Controlled Trials. Search strategies were developed with a medical librarian and revised through a peer review of electronic search strategies. All databases were searched from inception to 14 April 2020. Only full-text articles available in English were included. All identified articles were reviewed independently and in duplicate using predetermined criteria. All study designs were eligible if they reported on comfort-holding in a PICU. Data were extracted independently and in duplicate. PRINCIPAL FINDINGS: Of 13,326 studies identified, 13 were included. Comfort-holding was studied in the context of end-of-life care, developmental care, mobilization, and as a unique intervention. Comfort-holding is common during end-of-life care with 77.8% of children held, but rare during acute management (51% of children < three years, < 5% of children ≥ three years). Commonly reported outcomes included child outcomes (e.g., physiologic measurements), safety outcomes (e.g., accidental line removal), parent outcomes (e.g., psychological symptoms), and frequency of holding. CONCLUSION: There is a paucity of literature on comfort-holding in PICUs. This scoping review identifies significant gaps in the literature, including assessment of child-based outcomes of comfort-holding or safety assessment of comfort-holding, and highlights core outcomes to consider in future evaluations of this intervention including child-based outcomes, parent-based outcomes, and safety of the intervention.

RéSUMé: OBJECTIF: Comprendre et résumer l'étendue des connaissances sur la pratique des étreintes de réconfort dans les unités de soins intensifs pédiatriques (USIP). SOURCES: Cette étude de portée a été réalisée en utilisant la méthodologie PRISMA. Une recherche de la littérature a été menée dans les bases de données MEDLINE, EMBASE, PsycINFO, CINAHL et dans le registre Cochrane CENTRAL d'études contrôlées. Les stratégies de recherche ont été élaborées avec un bibliothécaire médical et révisées au moyen d'un examen par les pairs des stratégies de recherche électronique. Toutes les bases de données ont été passées en revue de leur création au 14 avril 2020. Seuls les articles en texte intégral disponibles en anglais ont été inclus. Tous les articles identifiés ont été révisés indépendamment et en double à l'aide de critères prédéterminés. Tous les types de plans d'étude étaient admissibles s'ils abordaient le thème des étreintes de réconfort dans une USIP. Les données ont été extraites indépendamment et en double. CONSTATATIONS PRINCIPALES: Sur les 13 326 études identifiées, 13 ont été incluses. Les étreintes de réconfort ont été étudiées dans le contexte des soins de fin de vie, des soins développementaux, de la mobilisation et en tant qu'intervention unique. Les étreintes de réconfort sont une approche courante dans le cadre de soins de fin de vie, durant lesquels 77,8 % des enfants sont étreints, mais plus rares pendant la prise en charge aiguë (51 % des enfants < trois ans, < 5 % des enfants ≥ trois ans). Les résultats couramment rapportés comprenaient les issues pour les enfants (p. ex. mesures physiologiques), les issues en matière de sécurité (p. ex. retrait accidentel d'une ligne), les issues pour les parents (p. ex. symptômes psychologiques) et la fréquence des étreintes. CONCLUSION: Il n'existe que très peu de littérature s'intéressant aux étreintes de réconfort dans les USIP. Cette étude de portée identifie d'importantes lacunes dans la littérature, notamment l'évaluation des issues pour l'enfant suite à une étreinte de réconfort ou l'évaluation de la sécurité de telles étreintes, et met en évidence les issues principales dont il faudra tenir compte dans les évaluations futures de cette intervention, y compris les issues axées sur l'enfant, les issues basées sur les parents et la sécurité de l'intervention.

Interventions to improve the well-being of medical learners in Canada: a scoping review.

BACKGROUND: Medical education affects learner well-being. We explored the breadth and depth of interventions to improve the well-being of medical learners in Canada. METHODS: We searched MEDLINE, EMBASE, CINAHL and PsycINFO from inception to July 11, 2020, using the Arksey-O'Malley, 5-stage, scoping review method. We included interventions to improve well-being across 5 wellness domains (i.e., social, mental, physical, intellectual, occupational) for medical learners in Canada, grouped as undergraduate or graduate nonmedical (i.e., health sciences) students, undergraduate medical students or postgraduate medical students (i.e., residents). We categorized interventions as targeting the individual (learner), program (i.e., in which learners are enrolled) or system (i.e., higher education or health care) levels. RESULTS: Of 1753 studies identified, we included 65 interventions that aimed to improve well-being in 10 202 medical learners, published from 1972 through 2020; 52 (80%) were uncontrolled trials. The median year for intervention implementation was 2010 (range 1971-2018) and the median length was 3 months (range 1 h-48 mo). Most (n = 34, 52%) interventions were implemented with undergraduate medical students. Two interventions included only undergraduate, nonmedical students; none included graduate nonmedical students. Most studies (n = 51, 78%) targeted intellectual well-being, followed by occupational (n = 32, 49%) and social (n = 17, 26%) well-being. Among 19 interventions implemented for individuals, 14 (74%) were for medical students; of the 27 program-level interventions, 17 (63%) were for resident physicians. Most (n = 58, 89%) interventions reported positive well-being outcomes. INTERPRETATION: Many Canadian medical schools address intellectual, occupational and social well-being by targeting interventions at medical learners. Important emphasis on the mental and physical well-being of medical learners in Canada warrants further exploration.

Maternal perceptions of cesarean birth care: A qualitative study to inform ERAS guideline development.

BACKGROUND: Cesarean birth (CB) is the most common inpatient surgical procedure, and until recently, there were no internationally accepted, standardized clinical guidelines available. The Enhanced Recovery After Surgery (ERAS® ) program aims to improve outcomes through the development of international guidelines (IGs). As an ERAS IG for CB was being developed, this qualitative study was conducted to explore and consolidate women's experiences with CB. METHODS: Qualitative methods were used to assess the patient experience with current evidence-based CB protocols across operative phases. Twelve women who experienced CB at a single center in Canada were interviewed using an open-ended, semi-structured interview guide at six weeks postpartum. Two researchers coded the emerging themes separately and compared findings. RESULTS: Women described feeling informed, but felt they did not have a choice. Presurgery, women wanted more information about the risks of CB. Preoperatively, women expressed confusion with the procedures, but felt informed about local anesthesia and thermoregulation. Post-CB, women felt informed about pain and nausea control; however, urinary catheter removal was delayed when compared to the ERAS recommendations. Information about postpartum infant care was not well communicated, as many women were uninformed about delayed cord clamping and infant thermoregulation. CONCLUSIONS: This qualitative study provides opportunities to improve communication, the patient-practitioner relationship, and the overall satisfaction throughout the CB process. The findings support the implementation of patient decision aids and training with the shared decision model. The improved procedures recommended in the ERAS IG for CB have the potential to deliver significant improvements to patient care and patient satisfaction.

Bereavement interventions to support informal caregivers in the intensive care unit: a systematic review.

BACKGROUND: Informal caregivers of critically ill patients in intensive care unit (ICUs) experience negative psychological sequelae that worsen after death. We synthesized outcomes reported from ICU bereavement interventions intended to improve informal caregivers' ability to cope with grief. DATA SOURCES: MEDLINE, EMBASE, CINAHL and PsycINFO from inception to October 2020. STUDY SELECTION: Randomized controlled trials (RCTs) of bereavement interventions to support informal caregivers of adult patients who died in ICU. DATA EXTRACTION: Two reviewers independently extracted data in duplicate. Narrative synthesis was conducted. DATA SYNTHESIS: Bereavement interventions were categorized according to the UK National Institute for Health and Clinical Excellence three-tiered model of bereavement support according to the level of need: (1) Universal information provided to all those bereaved; (2) Selected or targeted non-specialist support provided to those who are at-risk of developing complex needs; and/or (3) Professional specialist interventions provided to those with a high level of complex needs. Outcome measures were synthesized according to core outcomes established for evaluating bereavement support for adults who have lost other adults to illness. RESULTS: Three studies of ICU bereavement interventions from 31 ICUs across 26 hospitals were included. One trial examining the effect of family presence at brain death assessment integrated all three categories of support but did not report significant improvement in emotional or psychological distress. Two other trials assessed a condolence letter intervention, which did not decrease grief symptoms and may have increased symptoms of depression and post-traumatic stress disorder, and a storytelling intervention that found no significant improvements in anxiety, depression, post-traumatic stress, or complicated grief. Four of nine core bereavement outcomes were not assessed anytime in follow-up. CONCLUSIONS: Currently available trial evidence is sparse and does not support the use of bereavement interventions for informal caregivers of critically ill patients who die in the ICU.

Are small-for-gestational-age preterm infants at increased risk of overweight? Statistical pitfalls in overadjusting for body size measures.

OBJECTIVE: The objective of this study is to analyze the effect of adjusting for body measures on the association between small for gestational age (SGA) and overweight at 3 years. STUDY DESIGN: Data were obtained from the Preterm Infant Multicenter Growth Study (n = 1089). Logistic regression was used, to adjust for confounders with additional adjustments separately for weight and height at 21 months. Marginal structural models (MSMs) estimated the direct effect of SGA on overweight. RESULTS: The crude and adjusted for confounders models yielded null associations between SGA and overweight. Adjusting for height yielded a positive association (odds ratio (OR): 2.31, 95% CI: 0.52-10.26) and adjusting for weight provided a significantly positive association (OR: 6.60, 95% CI: 1.10-37.14). The MSMs, with height and weight held constant, provided no evidence for a direct effect of SGA on overweight (OR: 0.83, 95% CI: 0.14-5.01, OR: 0.71, 95% CI: 0.18-2.81, respectively). CONCLUSION: Adjusting for body measures can change the association between SGA and overweight, providing spurious estimates.

Mental Health Interventions to Improve Psychological Outcomes in Informal Caregivers of Critically Ill Patients: A Systematic Review and Meta-Analysis.

OBJECTIVES: Determine effect of mental health interventions on psychologic outcomes in informal caregivers of critically ill patients. DATA SOURCES: Searches conducted in MEDLINE, Embase, and other databases from inception to October 31, 2019. STUDY SELECTION: Interventions for informal caregivers of critically ill patients in adult ICU, PICU, or neonatal ICU. DATA EXTRACTION: Two independent, blinded reviewers screened citations and extracted data. Random-effects models with inverse variance weighting pooled outcome data when suitable. Psychologic outcomes categorized: 1) negative (anxiety, depression, post-traumatic stress disorder, distress, and burden) or 2) positive (courage, humanity, justice, transcendence, temperance, and wisdom and knowledge). Stratification according to intervention type and patient population was performed. DATA SYNTHESIS: Of 11,201 studies, 102 interventional trials were included (n = 12,676 informal caregivers). Interventions targeted caregiver experience (n = 58), role (n = 6), or support (n = 38). Meta-analysis (56 randomized controlled trials; n = 22 [39%] in adult ICUs; n = 34 [61%] in neonatal ICU or PICU) demonstrated reduced anxiety (ratio of means = 0.92; 95% CI, 0.87-0.97) and depression (ratio of means = 0.83; 95% CI, 0.69-0.99), but not post-traumatic stress disorder (ratio of means = 0.91; 95% CI, 0.80-1.04) or distress (ratio of means = 1.01; 95% CI, 0.95-1.07) among informal caregivers randomized to mental health interventions compared with controls within 3 months post-ICU discharge. Increased humanity (ratio of means = 1.11; 95% CI, 1.07-1.15), transcendence (ratio of means = 1.11; 95% CI, 1.07-1.15), and caregiver burden (ratio of means = 1.08; 95% CI, 1.05-1.12) were observed. No significant effects of mental health interventions observed after 3 months postdischarge. CONCLUSIONS: Mental health interventions for caregivers of critically ill patients improved short-term anxiety, depression, humanity, and transcendence while increasing burden. Clinicians should consider short-term prescriptions of mental health interventions to informal caregivers of critically ill patients with capacity to manage interventions.

Impact of social media interventions and tools among informal caregivers of critically ill patients after patient admission to the intensive care unit: A scoping review.

BACKGROUND: The use of social media in healthcare continues to evolve. The purpose of this scoping review was to summarize existing research on the impact of social media interventions and tools among informal caregivers of critically ill patients after patient admission to the intensive care unit (ICU). METHODS: This review followed established scoping review methods, including an extensive a priori-defined search strategy implemented in the MEDLINE, EMBASE, PsycINFO, CINAHL, and the Cochrane CENTRAL Register of Controlled Trials databases to July 10, 2020. Primary research studies reporting on the use of social media by informal caregivers for critically ill patients were included. RESULTS: We identified 400 unique citations and thirty-one studies met the inclusion criteria. Nine were interventional trials-four randomized controlled trials (RCTs)-and a majority (n = 14) were conducted (i.e., data collected) between 2013 to 2015. Communication platforms (e.g., Text Messaging, Web Camera) were the most commonly used social media tool (n = 17), followed by social networking sites (e.g., Facebook, Instagram) (n = 6), and content communities (e.g., YouTube, SlideShare) (n = 5). Nine studies' primary objective was caregiver satisfaction, followed by self-care (n = 6), and health literacy (n = 5). Nearly every study reported an outcome on usage feasibility (e.g., user attitudes, preferences, demographics) (n = 30), and twenty-three studies reported an outcome related to patient and caregiver satisfaction. Among the studies that assessed statistical significance (n = 18), 12 reported statistically significant positive effects of social media use. Overall, 16 of the 31 studies reported positive conclusions (e.g., increased knowledge, satisfaction, involvement) regarding the use of social media among informal caregivers for critically ill patients. CONCLUSIONS: Social media has potential benefits for caregivers of the critically ill. More robust and clinically relevant studies are required to identify effective social media strategies used among caregivers for the critically ill.