Defining Pediatric Chronic Critical Illness: A Scoping Review.

BackgroundImprovements in the delivery of intensive care have increased survival among even the most critically ill children, thereby leading to a growing number of children with chronic complex medical conditions in the pediatric intensive care unit (PICU). Some of these children are at a significant risk of recurrent and prolonged critical illness, with higher morbidity and mortality, making them a unique population described as having chronic critical illness (CCI). To date, pediatric CCI has been understudied and lacks an accepted consensus case definition.ObjectiveThis study aims to describe the protocol and methodology used to perform a scoping review that will describe how pediatric CCI has been defined in the literature, including the concept of prolonged PICU admission and the methodologies used to develop any existing definitions. It also aims to describe patient characteristics and outcomes evaluated in the included studies.MethodsWe will search four electronic databases for studies that evaluated children admitted to any PICU identified with CCI. We will also search for studies describing prolonged PICU admission, as this concept is related to pediatric CCI. Furthermore, we will develop a hybrid crowdsourcing and machine learning (ML) methodology to complete citation screening. Screening and data abstraction will be performed by 2 reviewers independently and in duplicate. Data abstraction will include the details of population definitions, demographic and clinical characteristics of children with CCI, and evaluated outcomes.ResultsThe database search, crowd reviewer recruitment, and ML algorithm development began in March 2021. Citation screening and data abstraction were completed in April 2021. Final data verification is ongoing, with analysis and results anticipated to be completed by fall 2021.ConclusionsThis scoping review will describe the existing or suggested definitions of pediatric CCI and important demographic and clinical characteristics of patients to whom these definitions have been applied. This review’s results will help inform the development of a consensus case definition for pediatric CCI and set a priority agenda for future research. We will use and demonstrate the validity of crowdsourcing and ML methodologies for improving the efficiency of large scoping reviews.International Registered Report Identifier (IRRID)DERR1-10.2196/30582

Background and Objectives: Chronic critical illness (CCI) is a syndrome characterized by persistent organ dysfunction that requires critical care therapy for ≥14 days. Sepsis and respiratory failure constitute the two primary causes of CCI. A better understanding of this patient population and their clinical course may help to risk-stratify them early during hospitalization. Our objective was to identify whether the source of sepsis (medical versus surgical) affected clinical trajectory and prognosis in patients developing CCI. Materials and Methods: We describe a cohort of patients having acute respiratory failure and sepsis and requiring critical care therapy in the medical (MICU) or surgical (SICU) critical care units for ≥14 days. Given the relative infrequency of CCI, we use a case series design to examine mortality, functional status, and place of residence (home versus non-home) at one year following their index hospitalization. Results: In medical patients developing CCI (n = 31), the severity of initial organ dysfunction, by SOFA score, was significantly associated with the development of CCI (p = 0.002). Surgical patients with CCI (n = 7) experienced significantly more ventilator-free days within the first 30 days following sepsis onset (p = 0.004), as well as less organ dysfunction at day 14 post-sepsis (p < 0.0001). However, one-year mortality, one-year functional status, and residency at home were not statistically different between cohorts. Moreover, 57% of surgical patients and 26% of medical patients who developed CCI were living at home for one year following their index hospitalization (p = 0.11). Conclusions: While surgical patients who develop sepsis-related CCI experience more favorable 30-day outcomes as compared with medical patients, long-term outcomes do not differ significantly between groups. This suggests that reversing established organ dysfunction and functional disability, regardless of etiology, is more challenging compared to preventing these complications at an earlier stage.

The past 2 decades have seen an expanding pediatric population that is chronically critically ill: children with repeated and prolonged hospitalizations and ongoing dependence on technologies to sustain vital functions. Although illness complexity prompts many hospitalizations, our goal with this study was to explore modifiable patient, family, and health system contributions to excess hospital days for children with chronic critical illness (CCI). Semistructured interviews were conducted with 51 stakeholders known for their CCI expertise. Stakeholders were from 5 metropolitan areas and were either (1) interdisciplinary providers (inpatient and/or outpatient clinicians, home health providers, foster care affiliates, or policy professionals) or (2) parents of children with CCI. Interview transcripts were qualitatively analyzed for themes. All stakeholders agreed that homelike settings are ideal care sites for children with CCI, yet in every region these children experience prolonged hospitalizations. The perceived causes of excess hospital days are (1) inadequate communication and coordination within health care teams and between clinicians and families, (2) widespread gaps in qualified pediatric home health services and durable medical equipment providers, (3) inconsistent parent support, and (4) policies that limit pediatric service eligibility, state-supported case management, and nonhospital care sites. Despite an expanding pediatric population with CCI, we lack an intentional care model to minimize their hospitalizations. In this study, we generate several hypotheses for exploring the potential impact of expanded access to home nursing, robust care coordination, and family and clinician support to reduce hospital days for this population of high health care utilizers.

Sepsis remains a leading cause of morbidity and mortality worldwide, with survivors often following divergent trajectories: rapid recovery (RAP) or progression to chronic critical illness (CCI). CCI is characterized by persistent organ dysfunction, recurrent infections, and immune dysregulation. Myeloid-derived suppressor cells (MDSCs), which expand in number after sepsis, are implicated in this maladaptive state, yet their epigenetic regulation remains poorly understood. Here, we applied an Omni-ATAC protocol optimized to profile chromatin accessibility in CD66b + MDSCs from healthy participants (HPs) and sepsis patients across time points (day 4, day 14-21, and 6 months) and clinical outcomes (RAP, CCI, and Deceased). Dimensionality reduction analyses of genome-wide chromatin accessibility showed clear separation of sepsis and HP samples. Furthermore, these analyses revealed distinct trajectories post-sepsis diagnosis: RAP samples progressively regained HP-like chromatin states, whereas CCI samples remained epigenetically "locked" in aberrant states. Differential accessibility analysis identified thousands of promoter regions with altered accessibility, including immune checkpoint and inflammatory genes (e.g., ARG1, CD274, S100A8 / 9 ). Pathway analyses predicted global suppression of immune, metabolic, and chromatin remodeling programs in CCI, contrasting with restoration in RAP. These findings from patient-derived CD66b + MDSCs suggest that epigenetic chromatin remodeling underlies divergent recovery trajectories and highlight chromatin-modifying pathways as potential therapeutic targets to restore immune competence in sepsis patients with CCI.

Children with medical complexity (CMC) and children with chronic critical illness (CCI) represent growing populations with high healthcare use and dependence on specialized care, both in the hospital and community setting. Nutrition assessment and delivery represent critical components of addressing the short-term and long-term health needs for these populations across the care continuum. This article provides a framework and reviews existing literature for the assessment of nutrition status and subsequent delivery of nutrition prescriptions in CMC and children with CCI. The specific aims are to (1) describe the epidemiology of health services experience for CMC and children with CCI, with a focus on their nutrition outcomes; (2) detail how to assess their nutrition status and energy requirements; (3) review methods of delivery of the nutrient prescription; (4) introduce perioperative considerations; (5) highlight examples of special populations of CMC and children with CCI; and (6) propose future research initiatives to improve nutrition and overall outcomes for these populations.

With the advancement of medical care and the continuous improvement of organ support technologies, some critically ill patients survive the acute phase of their illness but still experience persistent organ dysfunction, necessitating long-term reliance on intensive care and organ support, known as chronic critical illness. Chronic critical illness is characterized by prolonged hospital stays, high mortality rates, and significant resource consumption. Patients with chronic critical illness often suffer from malnutrition, compromised immune function, and poor baseline health, which, combined with factors like shock or trauma, can lead to intestinal mucosal damage. Therefore, effective nutritional intervention for patients with chronic critical illness remains a key research focus. Nutritional therapy has emerged as one of the essential components of the overall treatment strategy for chronic critical illness. This paper aims to provide a comprehensive review of the latest research progress in nutritional support therapy for patients with chronic critical illness.

Advancements in early diagnosis and novel treatments for children with complex and chronic needs have improved their chances of survival. But many survive with complex medical needs and ongoing medical management in the setting of prognostic uncertainty. Their medical care relies more and more on preference-sensitive decisions, requiring medical team and family engagement in ethically challenging situations. Many families are unprepared as they face these ethical challenges and struggle to access relevant ethical resources. In this paper, Timmy's narrative, situated in the context of what is known about ethical challenges in the care of children with chronic critical illness (CCI), serves as a case study of the gap in available ethical resources to guide families in their approach to difficult decision making for children with significant medical complexity and CCI. Our author group, inclusive of parents of children with complex medical needs and medical professionals, identifies domains of ethical challenges facing families of children with CCI and we highlight the development of family/caregiver-oriented ethics resources as an essential expansion of pediatric bioethics.

The aims of this focused review of the literature on children surviving critical illness were to (1) determine whether health-related quality of life (HRQL) represents a clinically meaningful outcome measure for children surviving critical illness and (2) evaluate the HRQL measures implemented in pediatric critical care studies to date. This was a focused review of the literature from 1980 to 2015 based on a search of EMBASE/PubMed, MEDLINE and PsycInfo assessing trends and determinants of HRQL outcomes in children surviving critical illness. We also evaluated the psychometric properties of the HRQL instruments used in the studies identified by examining each measure's reported reliability, validity and sensitivity to clinical change. The literature search identified 253 pediatric articles for potential inclusion in the review, among which data from 78 studies were ultimately selected for inclusion. Of the 22 measures utilized in the studies reviewed, only four demonstrated excellent psychometric properties for use in pediatric critical care trials. Trends in HRQL identified in the studies reviewed suggest significant ongoing morbidity for children surviving critical illness. Key determinants of poor HRQL outcomes include reason for PICU admission (sepsis, meningoencephalitis, trauma), antecedents (chronic comorbid conditions), treatments received (prolonged cardiopulmonary resuscitation, long-stay patients, invasive technology), psychological outcomes (post-traumatic stress disorder, parent anxiety/depression) and social and environmental characteristics (low socioeconomic status, parental education and functioning). Validated pediatric HRQL instruments are now available. Significant impact on HRQL has been demonstrated in acute and acute on chronic critical illness. Future pediatric critical care interventional trials should include both mortality as well as long-term HRQL measurements to truly ascertain the full impact of critical illness in children.

MOVING RIGHT ALONG: INCORPORATING PATIENT-SPECIFIC RISK FACTORS IN POST-CARDIAC SURGERY STERNAL PRECAUTIONS PRESCRIPTIONS

BackgroundInvolving people with lived experience in medical education can benefit them, their caregivers, and medical students, and may particularly impact medical education about children requiring comprehensive, individualized, multidisciplinary care, including those with medical complexity or developmental disabilities. Yet, there is no summary of how children with medical complexity or developmental disabilities, or their families or caregivers have been included in medical education for medical students, residents, and fellows. To advance the effective inclusion of lived experience in medical education related to this patient population, a synthesis of existing literature is needed.ObjectiveThis scoping review aims to identify and synthesize the literature on including the lived experiences of children with medical complexity or developmental disabilities and their caregivers in medical education, where in the curricular development process they are involved, and the level of engagement of people with lived experience in the process.MethodsTo complete the scoping review, MEDLINE, Scopus, PsycINFO, ERIC, Academic Search Premier, and Google Scholar were searched for studies investigating patient and caregiver involvement in medical education related to children with medical complexity or developmental disabilities. Studies involving continuing professional development or patients who are not children with medical complexity or developmental disabilities were excluded. Data will be extracted to identify the stage of curriculum development in which lived experience is included based on Kern’s 6-step approach, and to examine the level of engagement in medical education of children with medical complexity or developmental disabilities, their families, or their caregivers. Data from the scoping review will be presented in tables, diagrams, or matrices to demonstrate how lived experience caring for children with medical complexity or children with developmental disabilities has been included in the 6 steps of curriculum development and to characterize the level of engagement of people with lived experience in this process. Descriptive analysis will be performed to identify the findings from the included sources pertaining to the research objective.ResultsDatabase searches were completed on April 19, 2024. In total, 4382 unique articles were identified and screened against the eligibility criteria in July 2024, resulting in 30 articles being included in the scoping review. Data extraction began in July 2024.ConclusionsOur results will identify areas of improvement for medical education pertaining to the care of children with medical complexity or developmental disabilities. The findings will support and contribute to the development of medical school curricula surrounding care for children with medical complexity and children with developmental disabilities that incorporate people with lived experience in crucial roles during curriculum development. These partnerships with people with lived experience will promote more patient- and family-centered physicians, leading to better care of children with medical complexity and children with developmental disabilities.International Registered Report Identifier (IRRID)DERR1-10.2196/64911

Bovine respiratory disease (BRD) is one of the most common diseases observed in dairy calves in both the pre- and postweaning periods. Despite its common occurrence, no formal synthesis (e.g., scoping review) of the scientific literature has been conducted surrounding diagnosing BRD in dairy calves. As such, the objective of this scoping review was to describe what case definitions for diagnosing BRD in dairy calves have been used in research. An initial search of peer-reviewed journals and the gray literature yielded 12,001 unique articles, of which 307 records containing 358 case definitions were included. Seven categories of diagnostic methods were used to categorize case definitions: clinical scoring systems alone were the most used diagnostic method (n = 148, 41%); followed by physical exam parameters alone (i.e., the study did not provide a detailed description of how the calf was assessed for each component of the physical exam [i.e., no description or scoring options reported]), n = 91, 25%); physical exam parameters in combination with other diagnostic methods (n = 40, 11%); thoracic ultrasound alone (n = 31, 9%); clinical scoring system in combination with other diagnostic methods (n = 23, 7%); clinical scoring system in combination with thoracic ultrasound (n = 10, 3%); and other diagnostic methods (n = 15, 4%). Only two-thirds of publications provided a citation for their case definition (n = 230, 64%), of which the Wisconsin clinical scoring system was most referenced (n = 100, 43%), followed by the California clinical scoring system (n = 19, 8%). An attempt was made to compare entire case definitions within each diagnostic method; however, they displayed substantial diversity, which limited the ability to compare them at this level. Instead, counts of individual factors within each case definition (e.g., individual clinical signs) were reported for each diagnostic method. From all case definitions across the 7 diagnostic method categories (n = 358), common factors assessed included cough (n = 224, 63%), nasal discharge (n = 213, 60%), and body temperature (n = 142, 54%). Across all case definitions, additional parameters such as validity were frequently not reported; only 4 (1.1%) were referred to as validated, 9 (2.5%) were being validated in the study, and 28 (7.8%) modified existing case definitions. Additionally, assessment of severity of disease when present (e.g., mild, moderate or severe) was frequently not reported (n = 336, 93.9%). Further, 106 (29.0%) reported assessments of accuracy, 66 (18.4%) of which were reports of qualitative oversight (e.g., training of assessors), and 40 (11.1%) of which were related to a quantitative assessment of accuracy (e.g., sensitivity and specificity). Parameters surrounding conducting the assessment were also extracted, for example how often it was conducted (most common: at least daily, n = 120, 33.5%) and who conducted it (most common: information not reported, n = 144, 40.2%). The findings of this scoping review highlighted the need for a validated, standardized set of criteria for BRD diagnosis in dairy calves, achievable through following the methodology of developing a core outcome set.

Corticomuscular coherence (CMC) quantifies the frequency-specific coupling between cortical and muscular activity and is increasingly used to probe motor-control mechanisms. However, the factors that consistently influence CMC in axial and lower-limb muscles remain unclear. The objective of this study is to map and critically describe experimental factors and methodological choices that have been studied and their potential influence on CMC of axial and lower limb muscles measured in healthy humans. A scoping review was conducted following PRISMA-ScR guidelines. CINAHL, MEDLINE (Ovid), Embase, and Web of Science were searched from the date of inception to March 5th, 2024. Eligible studies that (i) computed CMC, (ii) recorded cortical activity with EEG or MEG, (iii) analyzed trunk or lower limb EMG, and (iv) compared CMC across experimental conditions or participant groups were included. Two reviewers independently screened records, extracted demographic, neurophysiological, task, and signal-processing variables, and grouped studies by the factor examined; third reviewer resolved discrepancies. Results were synthesized descriptively. Four factors showed the most consistent influence on CMC: (1) Age: younger adults exhibit higher CMC than older adults (2) Muscle-specificity: the tibialis anterior (TA) displays stronger CMC than other axial or lower-limb muscles; (3) Contraction type: isotonic and eccentric/quasi-isotonic contractions elicit greater CMC than isometric contractions; (4) Athletic status: non-athletes demonstrate higher CMC than trained individuals. The effects of fatigue, contraction intensity, posture, or walking tasks were inconsistent. Methodologically, most studies employed EEG (single Cz channel) and rectified EMG; MEG, source localization, and longitudinal approaches were seldom used. Current evidence indicates that participant characteristics (age, athletic status) and task parameters (muscle tested, contraction type) can impact CMC, but heterogeneity in study design and analysis hampers direct comparison and causal inference. Future research should adopt longitudinal designs, standardized protocols, and advanced source localization techniques to clarify the mechanisms governing CMC in axial and lower-limb musculature.

BackgroundIn high-income countries (HICs), between 65% and 70% of community-dwelling adults aged 65 and older are at high nutrition risk. Nutrition risk is the risk of poor dietary intake and nutritional status. Consequences of high nutrition risk include frailty, hospitalization, death, and reduced quality of life. Social factors (such as social support and commensality) are known to influence eating behavior in later life; however, to the authors’ knowledge, no reviews have been conducted examining how these social factors are associated with nutrition risk specifically.ObjectiveThe objective of this scoping review is to understand the extent and type of evidence concerning the relationship between social factors and nutrition risk among community-dwelling older adults in HICs and to identify social interventions that address nutrition risk in community-dwelling older adults in HICs.MethodsThis review will follow the scoping review methodology as outlined by the JBI Manual for Evidence Synthesis and the PRISMA-ScR (Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews) guidelines. The search will include MEDLINE (Ovid), CINAHL, PsycINFO, and Web of Science. There will be no date limits placed on the search. However, only resources available in English will be included. EndNote (Clarivate Analytics) and Covidence (Veritas Health Innovation Ltd) will be used for reference management and removal of duplicate studies. Articles will be screened, and data will be extracted by at least 2 independent reviewers using Covidence. Data to be extracted will include study characteristics (country, methods, aims, design, and dates), participant characteristics (population description, inclusion and exclusion criteria, recruitment method, total number of participants, and demographics), how nutrition risk was measured (including the tool used to measure nutrition risk), social factors or interventions examined (including how these were measured or determined), the relationship between nutrition risk and the social factors examined, and the details of social interventions designed to address nutrition risk.ResultsThe scoping review was started in October 2023 and will be finalized by August 2024. The findings will describe the social factors commonly examined in the nutrition risk literature, the relationship between these social factors and nutrition risk, the social factors that have an impact on nutrition risk, and social interventions designed to address nutrition risk. The results of the extracted data will be presented in the form of a narrative summary with accompanying tables.ConclusionsGiven the high prevalence of nutrition risk in community-dwelling older adults in HICs and the negative consequences of nutrition risk, it is essential to understand the social factors associated with nutrition risk. The results of the review are anticipated to aid in identifying individuals who should be screened proactively for nutrition risk and inform programs, policies, and interventions designed to reduce the prevalence of nutrition risk.International Registered Report Identifier (IRRID)DERR1-10.2196/56714

IntroductionSocial networks can affect health beliefs, behaviours and outcomes through various mechanisms, including social support, social influence and information diffusion. Social network analysis (SNA), an approach which emerged from the...

Intersection of Mental Health and Dysphonia: A Scoping Review