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OBJECTIVE: Perform a scoping review of supervised machine learning in pediatric critical care to identify published applications, methodologies, and implementation frequency to inform best practices for the development, validation, and reporting of predictive models in pediatric critical care. DESIGN: Scoping review and expert opinion. SETTING: We queried CINAHL Plus with Full Text (EBSCO), Cochrane Library (Wiley), Embase (Elsevier), Ovid Medline, and PubMed for articles published between 2000 and 2022 related to machine learning concepts and pediatric critical illness. Articles were excluded if the majority of patients were adults or neonates, if unsupervised machine learning was the primary methodology, or if information related to the development, validation, and/or implementation of the model was not reported. Article selection and data extraction were performed using dual review in the Covidence tool, with discrepancies resolved by consensus. SUBJECTS: Articles reporting on the development, validation, or implementation of supervised machine learning models in the field of pediatric critical care medicine. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Of 5075 identified studies, 141 articles were included. Studies were primarily (57%) performed at a single site. The majority took place in the United States (70%). Most were retrospective observational cohort studies. More than three-quarters of the articles were published between 2018 and 2022. The most common algorithms included logistic regression and random forest. Predicted events were most commonly death, transfer to ICU, and sepsis. Only 14% of articles reported external validation, and only a single model was implemented at publication. Reporting of validation methods, performance assessments, and implementation varied widely. Follow-up with authors suggests that implementation remains uncommon after model publication. CONCLUSIONS: Publication of supervised machine learning models to address clinical challenges in pediatric critical care medicine has increased dramatically in the last 5 years. While these approaches have the potential to benefit children with critical illness, the literature demonstrates incomplete reporting, absence of external validation, and infrequent clinical implementation.
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Enfermedad Crítica , Sepsis , Adulto , Recién Nacido , Humanos , Niño , Ciencia de los Datos , Estudios Retrospectivos , Cuidados Críticos , Sepsis/diagnóstico , Sepsis/terapia , Aprendizaje Automático SupervisadoRESUMEN
BACKGROUND: Preliminary evidence suggests that non-lung organ donation from resolved, asymptomatic or mildly symptomatic SARS-CoV-2 infected adults may be safe. However, several biological aspects of SARS-CoV-2 infection differ in children and the risk for transmission and outcomes of recipients from pediatric donors with SARS-CoV-2 infection are not well described. METHODS: We report two unvaccinated asymptomatic pediatric non-lung organ deceased donors who tested positive for SARS-CoV-2 RNA by RT-PCR. Donor One unexpectedly had SARS-CoV-2 RNA detected in nasopharyngeal swab and plasma specimens at autopsy despite several negative tests (upper and lower respiratory tract) in the days prior to organ recovery. Donor Two had SARS-CoV- 2 RNA detected in multiple nasopharyngeal swabs but not lower respiratory tract specimens (endotracheal aspirate and bronchoalveolar lavage) during routine surveillance prior to organ recovery and was managed with remdesivir and monoclonal antibodies prior to organ recovery. RESULTS: Two hearts, two livers and four kidneys were successfully transplanted into seven recipients. No donor to recipient transmission of SARS-CoV-2 was observed and graft function of all organs has remained excellent for up to 7 months of followup. CONCLUSIONS: Due to the persistent gap between organ availability and the number of children waiting for transplants, deceased pediatric patients with non-disseminated SARS-CoV-2 infection, isolated to upper and/or lower respiratory tract, should be considered as potential non-lung organ donors.
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COVID-19 , Trasplante de Órganos , Obtención de Tejidos y Órganos , Adulto , Humanos , Niño , COVID-19/diagnóstico , COVID-19/epidemiología , SARS-CoV-2 , ARN Viral , Donantes de TejidosRESUMEN
Prior criteria for organ dysfunction in critically ill children were based mainly on expert opinion. We convened the Pediatric Organ Dysfunction Information Update Mandate (PODIUM) expert panel to summarize data characterizing single and multiple organ dysfunction and to derive contemporary criteria for pediatric organ dysfunction. The panel was composed of 88 members representing 47 institutions and 7 countries. We conducted systematic reviews of the literature to derive evidence-based criteria for single organ dysfunction for neurologic, cardiovascular, respiratory, gastrointestinal, acute liver, renal, hematologic, coagulation, endocrine, endothelial, and immune system dysfunction. We searched PubMed and Embase from January 1992 to January 2020. Study identification was accomplished using a combination of medical subject headings terms and keywords related to concepts of pediatric organ dysfunction. Electronic searches were performed by medical librarians. Studies were eligible for inclusion if the authors reported original data collected in critically ill children; evaluated performance characteristics of scoring tools or clinical assessments for organ dysfunction; and assessed a patient-centered, clinically meaningful outcome. Data were abstracted from each included study into an electronic data extraction form. Risk of bias was assessed using the Quality in Prognosis Studies tool. Consensus was achieved for a final set of 43 criteria for pediatric organ dysfunction through iterative voting and discussion. Although the PODIUM criteria for organ dysfunction were limited by available evidence and will require validation, they provide a contemporary foundation for researchers to identify and study single and multiple organ dysfunction in critically ill children.
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Insuficiencia Multiorgánica/diagnóstico , Puntuaciones en la Disfunción de Órganos , Niño , Cuidados Críticos , Enfermedad Crítica , Medicina Basada en la Evidencia , Humanos , Insuficiencia Multiorgánica/terapiaRESUMEN
OBJECTIVES: To determine risk factors and outcomes associated with delirium in PICU patients. DESIGN: Retrospective cohort study. SETTING: Thirty-two-bed PICU within a tertiary care academic children's hospital. PATIENTS: All children admitted to the PICU March 1, 2014, to October 1, 2016, with at least one Cornell Assessment of Pediatric Delirium score (n = 2,446). INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Cornell Assessment of Pediatric Delirium score was performed twice daily as standard of care. We characterized delirium as: 1) presence of greater than or equal to 1 positive score (Cornell Assessment of Pediatric Delirium ≥ 9) and 2) number of days with a positive score. We built multivariable logistic and linear regression models using electronic medical records data. Many patients (n = 1,538; 63%) had a short length of stay (< 48 hr). Compared with patients with length of stay greater than or equal to 48 hours, fewer experienced delirium (30% vs 69%; p < 0.0001). Among 908 patients with length of stay greater than or equal to 48 hours, presence of delirium was independently associated with age less than 2 years old, baseline cognitive dysfunction, primary diagnosis, and duration of mechanical ventilation. Benzodiazepines demonstrated a dose-response effect (odds ratio for presence of delirium, 1.8 [p = 0.03], 3.4 [p < 0.001], and 9.7 [p = 0.005] for < 25th percentile, 25-75th percentile, and > 75th percentile of total dose, vs no exposure). In terms of outcomes, presence of delirium was independently associated with increased ICU length of stay (p < 0.001), whereas days of delirium were independently associated with decline in cognitive function from ICU admission to discharge (odds ratio, 1.06; p < 0.001), increased ICU (p < 0.001), and hospital length of stay (p < 0.001). Neither delirium presence nor total days were independently associated with mortality. CONCLUSIONS: Delirium is common in the PICU, particularly among patients with length of stay greater than or equal to 48 hours. It is independently associated with patient characteristics and PICU exposures, including benzodiazepines. The role of delirium as an independent causal factor in patient outcome requires further investigation.
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Delirio/epidemiología , Unidades de Cuidado Intensivo Pediátrico , Benzodiazepinas/administración & dosificación , Niño , Preescolar , Delirio/diagnóstico , Delirio/terapia , Femenino , Humanos , Hipnóticos y Sedantes/administración & dosificación , Lactante , Tiempo de Internación , Masculino , Alta del Paciente , Respiración Artificial , Estudios Retrospectivos , Factores de Riesgo , Centros de Atención Terciaria , Factores de Tiempo , Resultado del TratamientoRESUMEN
OBJECTIVES: We sought to describe current outcomes of Multiple Organ Dysfunction Syndrome present on day 1 of PICU admission. DESIGN: Retrospective observational cohort study. SETTING: Virtual Pediatric Systems, LLC, database admissions, January 2014 and December 2015. PATIENTS: We analyzed 194,017 consecutive PICU admissions, (age 1 mo to 18 yr) from the 2014-2015 Virtual Pediatric Systems database. INTERVENTIONS: We identified day 1 Multiple Organ Dysfunction Syndrome by International Pediatric Sepsis Consensus Conference criteria with day 1 laboratory and vital sign values. Functional status was evaluated by Pediatric Overall Performance Category and Pediatric Cerebral Performance Category scores from PICU admission and discharge. MEASUREMENTS AND MAIN RESULTS: Overall, PICU mortality was 2.1%. We identified day 1 Multiple Organ Dysfunction Syndrome in 14.4% of admissions. Patients with Multiple Organ Dysfunction Syndrome had higher mortality than those without Multiple Organ Dysfunction Syndrome (10.3% vs 0.7%; p < 0.0001), and a higher percentage of survivors had greater than or equal to 2 category worsening in Pediatric Cerebral Performance Category score (3.6% vs 0.5%; p < 0.0001) or Pediatric Overall Performance Category score (6.0% vs 1.8%; p < 0.0001). The odds of death with day 1 Multiple Organ Dysfunction Syndrome was 14.3 (95% CI, 13-15.7), while the odds of death or discharge with Pediatric Overall Performance Category/Pediatric Cerebral Performance Category score greater than or equal to 3 (poor functional outcome) was 6.7 (95% CI, 6-7.4). In a subset of 148,188 patients from hospitals where limitation of support decisions were recorded, 5.8% patients with Multiple Organ Dysfunction Syndrome had limitation of support decisions in place, compared with 0.8% of patients without Multiple Organ Dysfunction Syndrome (p < 0.0001). Of day 1 Multiple Organ Dysfunction Syndrome patients who died, 43.1% had limitation of support decisions in place, and 41.6% had withdrawal of life-sustaining therapies (p < 0.0001). CONCLUSIONS: Multiple Organ Dysfunction Syndrome present on day 1 of admission continues to be a major source of morbidity and mortality in the PICU, but risk of poor neurologic outcome may be improved. Further research is needed to understand decisions regarding limitation of support and withdrawal of life-sustaining therapy decisions in patients admitted with day 1 Multiple Organ Dysfunction Syndrome.
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Unidades de Cuidado Intensivo Pediátrico , Insuficiencia Multiorgánica/epidemiología , Adolescente , Niño , Preescolar , Femenino , Mortalidad Hospitalaria , Humanos , Lactante , Masculino , Insuficiencia Multiorgánica/mortalidad , Puntuaciones en la Disfunción de Órganos , Evaluación de Resultado en la Atención de Salud , Admisión del Paciente , Estudios Retrospectivos , Factores de Riesgo , Tasa de Supervivencia , Factores de TiempoRESUMEN
Patients with muscular temporomandibular disorder (TMD) present with abnormal oxygenation of the jaw muscles. Nonetheless, the deoxygenation pattern of jaw muscles of healthy subjects with frequent wake-time tooth-clenching episodes, who are at greater risk for TMD, has never been investigated. This case-control study compared the deoxygenation of the masseter during standardized tasks between TMD-free individuals with frequent self-reports of wake-time clenching and those with infrequent self-reports. University students ( N = 255) filled out the Oral Behavior Checklist. Fourteen females with high versus low scores-high parafunctional (HP) group ( n = 7, ≥80th percentile of score distribution) versus low parafunctional (LP) group ( n = 7, ≤20th percentile)-completed 2 sessions during which they clenched at their maximum voluntary contraction (MVC) for 2 min and at 10% to 20% MVC for 20 min. Tissue oxygen saturation (StO2) and changes in oxygenated hemoglobin, deoxygenated hemoglobin, and total hemoglobin of the masseter were measured via near-infrared spectroscopy and analyzed with a generalized mixed effect model. A significant interaction effect (task × study group) was found on all outcome measures, indicating that the deoxygenation pattern of the HP group differed from the LP group (all P < 0.001). MVC of the masseter induced an almost 5-times-greater reduction of StO2 in the HP group as compared with the LP group ( P = 0.023). However, the relative increase in StO2 at rest after the MVC was similar between groups ( P > 0.05). At the end of the prolonged MVC task (10% to 20%), the blood flow (change in total hemoglobin) was almost 6 times higher in the LP group as compared with baseline. On the contrary, it increased minimally in the HP group (all P < 0.001). Healthy individuals at risk for TMD have abnormalities in masseter deoxygenation. Future prospective studies are needed to test whether this contributes to the onset of muscular TMD.
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Bruxismo , Músculo Masetero/fisiopatología , Oxígeno , Trastornos de la Articulación Temporomandibular , Adulto , Estudios de Casos y Controles , Electromiografía , Femenino , Humanos , Contracción MuscularRESUMEN
While there is now an established recognition of microplastic pollution in the oceans, and the detrimental effects this may have on marine animals, the ocean depth at which such contamination is ingested by organisms has still not been established. Here, we detect the presence of ingested microplastics in the hindguts of Lysianassoidea amphipod populations, in six deep ocean trenches from around the Pacific Rim (Japan, Izu-Bonin, Mariana, Kermadec, New Hebrides and the Peru-Chile trenches), at depths ranging from 7000 m to 10 890 m. This illustrates that microplastic contaminants occur in the very deepest reaches of the oceans. Over 72% of individuals examined (65 of 90) contained at least one microparticle. The number of microparticles ingested per individual across all trenches ranged from 1 to 8. The mean and standard error of microparticles varied per trench, from 0.9 ± 0.4 (New Hebrides Trench) to 3.3 ± 0.7 (Mariana Trench). A subsample of microfibres and fragments analysed using FTIR were found to be a collection of plastic and synthetic materials (Nylon, polyethylene, polyamide, polyvinyl alcohol, polyvinylchloride, often with inorganic filler material), semi-synthetic (rayon and lyocell) and natural fibre (ramie). Notwithstanding, this study reports the deepest record of microplastic ingestion, indicating that anthropogenic debris is bioavailable to organisms at some of the deepest locations in the Earth's oceans.
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OBJECTIVES: Mortality from pediatric sepsis has steadily declined over the past several decades; however, little is known about morbidity among survivors. We aimed to determine the prevalence of and risk factors for failure to recover to baseline health-related quality of life following community-acquired pediatric sepsis. DESIGN: Retrospective cohort study. SETTING: Seattle Children's Hospital. PATIENTS: Children aged 1 month to 21 years admitted to the inpatient wards or ICUs from 2012 to 2015 who met 2005 consensus sepsis criteria within 4 hours of hospitalization and were enrolled in the hospital's Outcomes Assessment Program with baseline, admission, and post-discharge health-related quality of life data available. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: We assessed health-related quality of life with the Pediatric Quality of Life Inventory for pre-admission baseline, admission, and post-discharge (median, 31 d) status. We determined associations between patient and illness characteristics with failure to recover within 4.5 points of baseline at follow-up (the minimum clinically significant difference between two scores). Of 790 patients, 23.8% failed to recover to baseline health-related quality of life at follow-up. Factors associated with failure to recover were septic shock, older age, private insurance, complex chronic disease, immune compromise, CNS infection or bacteremia, ICU admission, and longer length of stay. On multivariable analysis controlling for time to follow-up, failure to recover was independently associated with septic shock (relative risk, 1.79; 95% CI, 1.24-2.58), older age (relative risk, 1.02/yr; 95% CI, 1.01-1.05), immune compromise (relative risk, 1.83; 95% CI, 1.40-2.40), and length of stay (relative risk, 1.03/d; 95% CI, 1.01-1.04). CONCLUSIONS: Nearly one-quarter of children surviving hospitalization for community-acquired sepsis experienced a clinically significant deterioration in health-related quality of life. We identify risk factors for poor outcomes following sepsis and highlight the need for ongoing evaluation and treatment by primary and specialty care providers for pediatric sepsis survivors after hospital discharge.
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Calidad de Vida , Sepsis/fisiopatología , Sobrevivientes/estadística & datos numéricos , Adolescente , Factores de Edad , Niño , Preescolar , Infecciones Comunitarias Adquiridas , Comorbilidad , Femenino , Humanos , Lactante , Unidades de Cuidados Intensivos/estadística & datos numéricos , Tiempo de Internación/estadística & datos numéricos , Masculino , Alta del Paciente , Estudios Retrospectivos , Choque Séptico/fisiopatología , Factores Socioeconómicos , Adulto JovenRESUMEN
Patients on extracorporeal life support (ECLS) are at risk for central nervous system (CNS) injury. One potentially modifiable risk factor is site of arterial cannulation in venoarterial (VA) ECLS, as in most cases one can choose the femoral or carotid artery. There is acute alteration in cerebral blood flow with carotid cannulation, potentially increasing the risk of stroke. Children may have lower risk of stroke with carotid cannulation compared with adults because of impaired cerebral circulation with aging. Our objective was to evaluate risk of stroke with carotid versus femoral cannulation and determine whether this differs between children and adults. Using the Extracorporeal Life Support Organization Registry, we evaluated patients 6-40 years old on VA ECLS during 2000-2012. We used multivariable logistic regression to estimate the relationship between location of arterial cannulation and stroke. We included an interaction term to assess whether this was modified by age. One thousand five hundred eighteen patients were included in the analysis. There was a fourfold increased odds of CNS infarct (odds ratio [OR]: 4.03; 95% CI: 2.17-7.46) with carotid cannulation. This estimate was not modified by age. There is increased likelihood of stroke with carotid cannulation in patients 6-40 years old in comparison with femoral cannulation during VA ECLS.
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Oxigenación por Membrana Extracorpórea/efectos adversos , Accidente Cerebrovascular/etiología , Adolescente , Adulto , Cateterismo/efectos adversos , Circulación Cerebrovascular , Niño , Femenino , Humanos , Modelos Logísticos , Masculino , Estudios Retrospectivos , Factores de Riesgo , Adulto JovenRESUMEN
OBJECTIVES: To evaluate the effect of body mass index (BMI) on the prevalence, intensity and interference of pain in women, and how it affects quality of life and level of physical activity; and to determine independent predictors of pain intensity. DESIGN: Cross-sectional observational study. SETTINGS: Obesity treatment clinic, community and university laboratory. PARTICIPANTS: Seventy-three of 133 women aged 25-75 years reported the presence of pain for at least 2 weeks and were categorised according to BMI (normal weight, overweight, obese or morbidly obese). MAIN OUTCOME MEASURES: BMI and questionnaires [McGill Pain Questionnaire (MPQ), Brief Pain Inventory (BPI), Short-Form Health Survey-36 (SF-36) and Baecke Physical Activity Questionnaire]. RESULTS: Pain intensity was 3 and 4.5 times higher in the MPQ and BPI, respectively, in morbidly obese women compared with women of normal weight. Morbidly obese women had 10.7 times higher pain interference and lower scores on the SF-36 domains of physical function and role function-physical compared with women of normal weight. Obese and morbidly obese women had less pain relief from treatment. Regression analysis showed that high BMI and low level of physical activity contributed to the intensity of pain, and these variables explained 16% of the variance of pain intensity. CONCLUSIONS: This study found that the prevalence and intensity of pain are greater in morbidly obese women than women of normal weight, and pain is negatively associated with physical activity. The causal inter-relationships between pain, obesity and physical activity are complex and require further study.
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Ejercicio Físico , Sobrepeso/epidemiología , Dolor/epidemiología , Calidad de Vida , Adulto , Factores de Edad , Anciano , Índice de Masa Corporal , Estudios Transversales , Femenino , Estado de Salud , Humanos , Salud Mental , Persona de Mediana Edad , Limitación de la Movilidad , Obesidad Mórbida/epidemiología , Dimensión del Dolor , Índice de Severidad de la EnfermedadRESUMEN
BACKGROUND: Pain is prevalent in chronic obstructive pulmonary disease (COPD) and the Brief Pain Inventory (BPI) appears to be a feasible questionnaire to assess this symptom. However, the reliability and validity of the BPI have not been determined in individuals with COPD. This study aimed to determine the internal consistency, test-retest reliability and validity (construct, convergent, divergent and discriminant) of the BPI in individuals with COPD. METHODS: In order to examine the test-retest reliability, individuals with COPD were recruited from pulmonary rehabilitation programmes to complete the BPI twice 1 week apart. In order to investigate validity, de-identified data was retrieved from two previous studies, including forced expiratory volume in 1-s, age, sex and data from four questionnaires: the BPI, short-form McGill Pain Questionnaire (SF-MPQ), 36-Item Short Form Survey (SF-36) and Community Health Activities Model Program for Seniors (CHAMPS) questionnaire. RESULTS: In total, 123 participants were included in the analyses (eligible data were retrieved from 86 participants and additional 37 participants were recruited). The BPI demonstrated excellent internal consistency and test-retest reliability. It also showed convergent validity with the SF-MPQ and divergent validity with the SF-36. The factor analysis yielded two factors of the BPI, which demonstrated that the two domains of the BPI measure the intended constructs. The BPI can also discriminate pain levels among COPD patients with varied levels of quality of life (SF-36) and physical activity (CHAMPS). CONCLUSION: The BPI is a reliable and valid pain questionnaire that can be used to evaluate pain in COPD. SIGNIFICANCE: This study formally established the reliability and validity of the BPI in individuals with COPD, which have not been determined in this patient group. The results of this study provide strong evidence that assessment results from this pain questionnaire are reliable and valid.
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Dimensión del Dolor/métodos , Dolor/diagnóstico , Enfermedad Pulmonar Obstructiva Crónica/complicaciones , Anciano , Ejercicio Físico , Análisis Factorial , Femenino , Humanos , Masculino , Persona de Mediana Edad , Dolor/etiología , Psicometría , Calidad de Vida , Reproducibilidad de los Resultados , Encuestas y CuestionariosRESUMEN
BACKGROUND: Reduced heart rate variability (HRV), a marker of autonomic system dysfunction, has been reported in patients with chronic obstructive pulmonary disease (COPD). Yet, limited data exists on the reliability of HRV measurement in this population. Here we investigated the reliability of short-term HRV measurement performed during spontaneous breathing in patients with COPD. METHODS: Thirteen individuals (8 males) with moderate-to-severe COPD (FEV1 46±16% predicted; FEV1/FVC 49±13) underwent standard time and frequency domain HRV measurements derived from 5-minute electrocardiograms collected on two separate days using a SphygmoCor device. Absolute and relative reliability was assessed by a number of coefficients including within-subject random variation, systematic change in the mean, and retest correlations. RESULTS: Within-subject coefficients of variation (CV) ranged from 4.3% to 193.4%. The intraclass correlation coefficients (ICCs) ranged from 0.72 to 0.93 for parameters related to overall HRV, and from 0.57 to 0.59 for those related to parasympathetic tone in both time and frequency domains. Mean heart rate was the only parameter that showed excellent absolute and relative reliability (CV=4.3%, ICC=0.93). CONCLUSION: The HRV measurements showed overall moderate-to-substantial reliability during spontaneous breathing in COPD population. Our findings support the use of HRV parameters for diagnosis and cardiac risk assessment, but only mean heart rate can be used reliably for monitoring changes in autonomic status following rehabilitation intervention in this population.
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Frecuencia Cardíaca/fisiología , Enfermedad Pulmonar Obstructiva Crónica/fisiopatología , Respiración , Femenino , Pruebas de Función Cardíaca , Humanos , Masculino , Persona de Mediana Edad , Reproducibilidad de los Resultados , Factores de TiempoRESUMEN
OBJECTIVES: Previous studies have suggested an association between nonwhite race and poor outcomes in small subsets of cardiac surgery patients who require extracorporeal life support. This study aims to examine the association of race/ethnicity with mortality in pediatric patients who receive extracorporeal life support for cardiac support. DESIGN: Retrospective analysis of registry data. SETTING: Prospectively collected multi-institutional registry data. SUBJECTS: Data from all North American pediatric patients in the Extracorporeal Life Support International Registry who received extracorporeal life support for cardiac support between 1998 and 2012 were analyzed. Multivariate regression models were constructed to examine the association between race/ethnicity and hospital mortality, adjusting for demographics, diagnosis, pre-extracorporeal life support care, extracorporeal life support variables, and extracorporeal life support-related complications. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Of 7,106 patients undergoing cardiac extracorporeal life support, the majority of patients were of white race (56.9%) with black race (16.7%), Hispanic ethnicity (15.8%), and Asian race (2.8%) comprising the other major race/ethnic groups. The mortality rate was 53.9% (n = 3,831). After adjusting for covariates, multivariate analysis identified black race (relative risk = 1.10; 95% CI, 1.04-1.16) and Hispanic ethnicity (relative risk = 1.08; 95% CI, 1.02-1.14) as independent risk factors for mortality. CONCLUSIONS: Black race and Hispanic ethnicity are independently associated with mortality in children who require cardiac extracorporeal life support.
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Procedimientos Quirúrgicos Cardíacos/mortalidad , Oxigenación por Membrana Extracorpórea/mortalidad , Hispánicos o Latinos/estadística & datos numéricos , Mortalidad Hospitalaria/etnología , Grupos Raciales/estadística & datos numéricos , Adolescente , Pueblo Asiatico/estadística & datos numéricos , Población Negra/estadística & datos numéricos , Niño , Preescolar , Oxigenación por Membrana Extracorpórea/efectos adversos , Femenino , Cardiopatías Congénitas/mortalidad , Cardiopatías Congénitas/cirugía , Humanos , Lactante , Recién Nacido , Masculino , Miocarditis/mortalidad , Miocarditis/cirugía , América del Norte/epidemiología , Estudios Retrospectivos , Factores de Riesgo , Tasa de Supervivencia , Población Blanca/estadística & datos numéricosRESUMEN
The Southwest Indian Ridge is the longest section of very slow to ultraslow-spreading seafloor in the global mid-ocean ridge system, but the biogeography and ecology of its hydrothermal vent fauna are previously unknown. We collected 21 macro- and megafaunal taxa during the first Remotely Operated Vehicle dives to the Longqi vent field at 37° 47'S 49° 39'E, depth 2800 m. Six species are not yet known from other vents, while six other species are known from the Central Indian Ridge, and morphological and molecular analyses show that two further polychaete species are shared with vents beyond the Indian Ocean. Multivariate analysis of vent fauna across three oceans places Longqi in an Indian Ocean province of vent biogeography. Faunal zonation with increasing distance from vents is dominated by the gastropods Chrysomallon squamiferum and Gigantopelta aegis, mussel Bathymodiolus marisindicus, and Neolepas sp. stalked barnacle. Other taxa occur at lower abundance, in some cases contrasting with abundances at other vent fields, and δ13C and δ15N isotope values of species analysed from Longqi are similar to those of shared or related species elsewhere. This study provides baseline ecological observations prior to mineral exploration activities licensed at Longqi by the United Nations.
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Bivalvos/crecimiento & desarrollo , Gastrópodos/crecimiento & desarrollo , Respiraderos Hidrotermales/análisis , Poliquetos/crecimiento & desarrollo , Thoracica/crecimiento & desarrollo , Animales , Biodiversidad , Bivalvos/clasificación , Gastrópodos/clasificación , Océano Índico , Filogenia , Filogeografía , Poliquetos/clasificación , Tecnología de Sensores Remotos , Agua de Mar , Thoracica/clasificaciónRESUMEN
OBJECTIVES: To examine the proportionate use of critical care resources among children of differing medical complexity admitted to pediatric intensive care units (ICUs) in tertiary-care children's hospitals. STUDY DESIGN: This is a retrospective, cross-sectional study of all children (<19 years of age) admitted to a pediatric ICU between January 1, 2012, and December 31, 2013, in the Pediatric Health Information Systems database. Using the Pediatric Medical Complexity Algorithm, we assigned patients to 1 of 3 categories: no chronic disease, noncomplex chronic disease (NC-CD), or complex chronic disease (C-CD). Baseline demographics, hospital costs, and critical care resource use were stratified by these groups and summarized. RESULTS: Of 136 133 children with pediatric ICU admissions, 53.0% were categorized as having C-CD. At the individual-encounter level, ICU resource use was greatest among patients with C-CD compared with children with NC-CD and no chronic disease. At the hospital level, patients with C-CD accounted for more than 75% of all examined ICU resources, including ventilation days, ICU costs, extracorporeal membrane oxygenation runs, and arterial and central venous catheters. Children with a progressive condition accounted for one-half of all ICU resources. In contrast, patients with no chronic disease and NC-CD accounted for less than one-quarter of all ICU therapies. CONCLUSION: Children with medical complexity disproportionately use the majority of ICU resources in children's hospitals. Efforts to improve quality and provide cost-effective care should focus on this population.
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Cuidados Críticos/estadística & datos numéricos , Enfermedad Crítica/terapia , Adolescente , Algoritmos , Niño , Preescolar , Estudios Transversales , Femenino , Recursos en Salud/estadística & datos numéricos , Humanos , Lactante , Recién Nacido , Unidades de Cuidados Intensivos , Masculino , Estudios RetrospectivosRESUMEN
OBJECTIVES: To evaluate accuracy of 2 established administrative methods of identifying children with sepsis using a medical record review reference standard. STUDY DESIGN: Multicenter retrospective study at 6 US children's hospitals. Subjects were children >60 days to <19 years of age and identified in 4 groups based on International Classification of Diseases, Ninth Revision, Clinical Modification codes: (1) severe sepsis/septic shock (sepsis codes); (2) infection plus organ dysfunction (combination codes); (3) subjects without codes for infection, organ dysfunction, or severe sepsis; and (4) infection but not severe sepsis or organ dysfunction. Combination codes were allowed, but not required within the sepsis codes group. We determined the presence of reference standard severe sepsis according to consensus criteria. Logistic regression was performed to determine whether addition of codes for sepsis therapies improved case identification. RESULTS: A total of 130 out of 432 subjects met reference SD of severe sepsis. Sepsis codes had sensitivity 73% (95% CI 70-86), specificity 92% (95% CI 87-95), and positive predictive value 79% (95% CI 70-86). Combination codes had sensitivity 15% (95% CI 9-22), specificity 71% (95% CI 65-76), and positive predictive value 18% (95% CI 11-27). Slight improvements in model characteristics were observed when codes for vasoactive medications and endotracheal intubation were added to sepsis codes (c-statistic 0.83 vs 0.87, P = .008). CONCLUSIONS: Sepsis specific International Classification of Diseases, Ninth Revision, Clinical Modification codes identify pediatric patients with severe sepsis in administrative data more accurately than a combination of codes for infection plus organ dysfunction.
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Sepsis/diagnóstico , Choque Séptico/diagnóstico , Adolescente , Niño , Preescolar , Femenino , Humanos , Lactante , Clasificación Internacional de Enfermedades , Masculino , Valor Predictivo de las Pruebas , Estudios Retrospectivos , Sensibilidad y Especificidad , Estados Unidos , Adulto JovenRESUMEN
OBJECTIVE: End-tidal carbon dioxide (ETCO(2)) measurements during cardiopulmonary resuscitation (CPR) reflect variable cardiac output over time, and low values have been associated with decreased survival. The goals of this review are to confirm and quantify this relationship and to determine the mean ETCO(2) value among patients with return of spontaneous circulation (ROSC) as an initial step toward determining an appropriate target for intervention during resuscitation in the absence of prospective data. DATA SOURCES AND STUDY SELECTION: The PubMed database was searched for the key words "end-tidal carbon dioxide" or "capnometry" or "capnography" and "resuscitation" or "return of spontaneous circulation." Randomized controlled trials, cohort studies, or case-control studies that reported ETCO(2) values for participants with and without ROSC were included. DATA EXTRACTION AND SYNTHESIS: Twenty-seven studies met the inclusion criteria for qualitative synthesis. Twenty studies were included in determination of average ETCO(2) values. The mean ETCO(2) in participants with ROSC was 25.8 ± 9.8 mm Hg versus 13.1 ± 8.2 mm Hg (P = .001) in those without ROSC. Nineteen studies were included in a meta-analysis. The mean difference in ETCO(2) was 12.7 mm Hg (95% confidence interval: 10.3-15.1) between participants with and without ROSC (P < .001). The mean difference in ETCO(2) was not modified by the receipt of sodium bicarbonate, uncontrolled minute ventilation, or era of resuscitation guidelines. The overall quality of data by Grades of Recommendations, Assessment, Development and Evaluation criteria is very low, but no prospective data are currently available. CONCLUSIONS: Participants with ROSC after CPR have statistically higher levels of ETCO(2). The average ETCO(2) level of 25 mm Hg in participants with ROSC is notably higher than the threshold of 10 to 20 mm Hg to improve delivery of chest compressions. The ETCO(2) goals during resuscitation may be higher than previously suggested and further investigation into appropriate targets during resuscitation is needed to diminish morbidity and mortality after cardiorespiratory arrest.
Asunto(s)
Dióxido de Carbono/fisiología , Reanimación Cardiopulmonar , Paro Cardíaco/fisiopatología , Volumen de Ventilación Pulmonar/fisiología , Paro Cardíaco/mortalidad , Humanos , Estudios ProspectivosRESUMEN
PURPOSE: To identify physiotherapists' familiarity with and experience using outcome measures (OMs) along the care continuum for patients undergoing total joint arthroplasty (TJA) of the hip and knee. Views on future use and barriers were also captured. METHODS: A stratified random sample of physiotherapists in one Canadian province completed a questionnaire about 19 standardized and clinically feasible OMs. Analyses included descriptive statistics and chi-square and McNemar tests to compare use of OMs for clinical decision making and program evaluation. RESULTS: Of 694 physiotherapists surveyed, 298 (43%) responded. Of these, 172 (58%) treated TJA clients and completed the full questionnaire. A majority worked in public practice settings and >1 care phase (e.g., pre-op, acute, rehab). All physiotherapists reported using ≥1 OM and having greater experience using performance-based measures than patient-reported OMs. OMs were used more often for clinical decision making than for program evaluation. Dissatisfaction with available tools was evident from respondents' comments. Several barriers to using OMs were identified in varied clinical settings and care phases. CONCLUSIONS: While physiotherapists use a variety of OMs along the TJA continuum, there remain challenges to routine use across clinical settings, care phases, and patient sub-groups.
Objectif : Déterminer dans quelle mesure les physiothérapeutes savent bien utiliser les mesures des résultats (MR) sur le continuum des soins chez les patients qui subissent une arthroplastie totale (AT) de la hanche et du genou, ainsi que leur expérience en la matière. On a saisi aussi leur opinion sur l'utilisation future et les obstacles. Méthodes : Un échantillon aléatoire stratifié de physiothérapeutes d'une province du Canada a répondu à un questionnaire sur 19 MR normalisées et faisables sur le plan clinique. Les analyses ont inclus des statistiques descriptives et des tests du chi-carré et de McNemar afin de comparer l'utilisation des MR pour la prise de décisions cliniques et l'évaluation de programmes. Résultats : Sur 694 physiothérapeutes sondés, 298 (43%) ont répondu, dont 172 (58%) ont traité des clients qui ont subi une AT et répondu au questionnaire au complet. Une majorité d'entre eux travaillait en pratique publique et dans >1 phase de soins (p. ex., préopératoires, actifs, réadaptation). Tous les physiothérapeutes ont déclaré utiliser ≥1 MR et avoir plus d'expérience des mesures fondées sur le rendement que des MR déclarées par les patients. Les MR étaient utilisées plus souvent dans la prise de décisions cliniques que dans l'évaluation de programmes. Les commentaires des répondants ont révélé leur insatisfaction face aux outils disponibles. On a défini un certain nombre d'obstacles à l'utilisation des MR dans divers contextes cliniques et phases de soins. Conclusions : Les physiothérapeutes utilisent un éventail de MR sur tout le continuum de l'AT, mais il reste des défis à relever sur le plan de l'utilisation de routine entre les contextes cliniques, les phases de soins et les sous-groupes de patients.
RESUMEN
OBJECTIVES: To compare the prevalence, resource utilization, and mortality for pediatric severe sepsis identified using two established identification strategies. DESIGN: Observational cohort study from 2004 to 2012. SETTING: Forty-four pediatric hospitals contributing data to the Pediatric Health Information Systems database. PATIENTS: Children 18 years old or younger. MEASUREMENTS AND MAIN RESULTS: We identified patients with severe sepsis or septic shock by using two International Classification of Diseases, 9th edition, Clinical Modification-based coding strategies: 1) combinations of International Classification of Diseases, 9th edition, Clinical Modification codes for infection plus organ dysfunction (combination code cohort); 2) International Classification of Diseases, 9th edition, Clinical Modification codes for severe sepsis and septic shock (sepsis code cohort). Outcomes included prevalence of severe sepsis, as well as hospital and ICU length of stay, and mortality. Outcomes were compared between the two cohorts examining aggregate differences over the study period and trends over time. The combination code cohort identified 176,124 hospitalizations (3.1% of all hospitalizations), whereas the sepsis code cohort identified 25,236 hospitalizations (0.45%), a seven-fold difference. Between 2004 and 2012, the prevalence of sepsis increased from 3.7% to 4.4% using the combination code cohort and from 0.4% to 0.7% using the sepsis code cohort (p < 0.001 for trend in each cohort). Length of stay (hospital and ICU) and costs decreased in both cohorts over the study period (p < 0.001). Overall, hospital mortality was higher in the sepsis code cohort than the combination code cohort (21.2% [95% CI, 20.7-21.8] vs 8.2% [95% CI, 8.0-8.3]). Over the 9-year study period, there was an absolute reduction in mortality of 10.9% (p < 0.001) in the sepsis code cohort and 3.8% (p < 0.001) in the combination code cohort. CONCLUSIONS: Prevalence of pediatric severe sepsis increased in the studied U.S. children's hospitals over the past 9 years, whereas resource utilization and mortality decreased. Epidemiologic estimates of pediatric severe sepsis varied up to seven-fold depending on the strategy used for case ascertainment.