Incidence of mental health conditions following pediatric hospital admissions: analysis of a national database

IntroductionDespite increasing survival of children following hospitalization, hospitalization may increase iatrogenic risk for mental health (MH) disorders, including acute stress, post-traumatic stress, anxiety, or depression. Using a population-based retrospective cohort study, we assessed the rates of new MH diagnoses during the 12 months after hospitalization, including the moderating effects of ICU exposure.Study design/methodsThis was a retrospective case control study using the Truven Health Analytics insurance database. Inclusion criteria included children aged 3–21 years, insurance enrollment for >12 months before and after hospital admission. We excluded children with hospitalization 2 years prior to index hospitalization and those with prior MH diagnoses. We extracted admission type, ICD-10 codes, demographic, clinical, and service coordination variables from the database. We established age- and sex-matched cohorts of non-hospitalized children. The primary outcome was a new MH diagnosis. Multivariable regression methods examined the risk of incident MH disorder(s) between hospitalized and non-hospitalized children. Among hospitalized children, we further assessed effect modification from ICU (vs. non-ICU) stay, admission year, length of stay, medical complexity, and geographic region.ResultsNew MH diagnoses occurred among 19,418 (7%) hospitalized children, 3,336 (8%) ICU-hospitalized children and 28,209 (5%) matched healthy controls. The most common MH diagnoses were anxiety (2.5%), depression (1.9%), and stress/trauma (2.2%) disorders. Hospitalization increased the odds of new MH diagnoses by 12.3% (OR: 1.123, 95% CI: 1.079–1.17) and ICU-hospitalization increased these odds by 63% (OR: 1.63, 95% CI: 1.483–1.79) as compared to matched, non-hospitalized children. Children with non-complex chronic diseases (OR: 2.91, 95% CI: 2.84–2.977) and complex chronic diseases (OR: 5.16, 95% CI: 5.032–5.289) had a substantially higher risk for new MH diagnoses after hospitalization compared to patients with acute illnesses.ConclusionPediatric hospitalization is associated with higher, long-term risk of new mental health diagnoses, and ICU hospitalization further increases that risk within 12 months of the acute episode. Acute care hospitalization confers iatrogenic risks that warrant long-term mental and behavioral health follow-up

Age- and therapy-related effects on morphine requirements and plasma concentrations of morphine and its metabolites in postoperative infants

BACKGROUND: To investigate clinical variables such as gestational age, sex, weight, the therapeutic regimens used and mechanical ventilation that might affect morphine requirements and plasma concentrations of morphine and its metabolites. METHODS: In a double-blind study, neonates and infants stratified for age [group I 0-4 weeks (neonates), group II > or =4-26 weeks, group III > or =26-52 weeks, group IV > or =1-3 yr] admitted to the paediatric intensive care unit after abdominal or thoracic surgery received morphine 100 micro g kg(-1) after surgery, and were randomly assigned to either continuous morphine 10 micro g kg(-1) h(-1) or intermittent morphine boluses 30 micro g kg(-1) every 3 h. Pain was measured using the COMFORT behavioural scale and a visual analogue scale. Additional morphine was adm

Plasma biomarker analysis in pediatric ARDS: Generating future framework from a pilot randomized control trial of methylprednisolone: A framework for identifying plasma biomarkers related to clinical outcomes in pediatric ARDS

© 2016 Kimura, Saravia, Rovnaghi, Meduri, Schwingshackl, Cormier and Anand. Objective: Lung injury activates multiple pro-inflammatory pathways, including neutrophils, epithelial, and endothelial injury, and coagulation factors leading to acute respiratory distress syndrome (ARDS). Low-dose methylprednisolone therapy (MPT) improved oxygenation and ventilation in early pediatric ARDS without altering duration of mechanical ventilation or mortality. We evaluated the effects of MPT on biomarkers of endothelial [Ang-2 and soluble intercellular adhesion molecule-1 (sICAM-1)] or epithelial [soluble receptor for activated glycation end products (sRAGE)] injury, neutrophil activation [matrix metalloproteinase-8 (MMP-8)], and coagulation (plasminogen activator inhibitor-1). Design: Double-blind, placebo-controlled randomized trial. Setting: Tertiary-care pediatric intensive care unit (ICU). Patients: Mechanically ventilated children (0-18 years) with early ARDS. Interventions: Blood samples were collected on days 0 (before MPT), 7, and 14 during low-dose MPT (n = 17) vs. placebo (n = 18) therapy. The MPT group received a 2-mg/kg loading dose followed by 1 mg/kg/day continuous infusions from days 1 to 7, tapered off over 7 days; placebo group received equivalent amounts of 0.9% saline. We analyzed plasma samples using a multiplex assay for five biomarkers of ARDS. Multiple regression models were constructed to predict associations between changes in biomarkers and the clinical outcomes reported earlier, including P/F ratio on days 8 and 9, plateau pressure on days 1 and 2, PaCO 2 on days 2 and 3, racemic epinephrine following extubation, and supplemental oxygen at ICU discharge. Results: No differences occurred in biomarker concentrations between the groups on day 0. On day 7, reduction in MMP-8 levels (p = 0.0016) occurred in the MPT group, whereas increases in sICAM-1 levels (p = 0.0005) occurred in the placebo group (no increases in sICAM-1 in the MPT group). sRAGE levels decreased in both MPT and placebo groups (p \u3c 0.0001) from day 0 to day 7. On day 7, sRAGE levels were positively correlated with MPT group PaO 2 /FiO 2 ratios on day 8 (r = 0.93, p = 0.024). O 2 requirements at ICU transfer positively correlated with day 7 MMP-8 (r = 0.85, p = 0.016) and Ang-2 levels (r = 0.79, p = 0.036) in the placebo group and inversely correlated with day 7 sICAM-1 levels (r = -0.91, p = 0.005) in the MPT group. Conclusion: Biomarkers selected from endothelial, epithelial, or intravascular factors can be correlated with clinical endpoints in pediatric ARDS. For example, MPT could reduce neutrophil activation ([downwards double arrow]MMP-8), decrease endothelial injury (⇔sICAM-1), and allow epithelial recovery ([downwards double arrow]sRAGE). Large ARDS clinical trials should develop similar frameworks

What is the definition of acute episodic and chronic pain in critically ill neonates and infants? : a global, four-stage consensus and validation study

Objectives To define and validate types of pain in critically ill neonates and infants by researchers and clinicians working in the neonatal intensive care unit (NICU) and high dependency unit (HDU). Design A qualitative descriptive mixed-methods design. Procedure/s Each stage of the study was built on and confirmed the previous stages. Stage 1 was an expert panel to develop definitions; stage 2 was a different expert panel made up of neonatal clinicians to propose clinical characteristics associated with the definitions from stage 1; stage 3 was a focus group of neonatal clinicians to provide clinical case scenarios associated with each definition and clinical characteristics; and stage 4 was a survey administered to neonatal clinicians internationally to test the validity of the definitions using the clinical case scenarios. Results In stage 1, the panel (n=10) developed consensus definitions for acute episodic pain and chronic pain in neonates and infants. In stage 2, a panel (n=8) established clinical characteristics that may be associated with each definition. In stage 3, a focus group (n=11) created clinical case scenarios of neonates and infants with acute episodic pain, chronic pain and no pain using the definitions and clinical characteristics. In stage 4, the survey (n=182) revealed that the definitions allowed an excellent level of discrimination between case scenarios that described neonates and infants with acute episodic pain and chronic pain (area under the receiver operating characteristic=0.87 and 0.89, respectively). Conclusions This four-stage study enabled the development of consensus-based and clinically valid definitions of acute episodic pain and chronic pain. There is a need to define and validate other pain types to inform a taxonomy of pain experienced by neonates and infants in the NICU and HDU

Work-Life Balance: Essential or Ephemeral?

Burn-out and suicide rates among physicians and scientists in academic medicine are at an all-time high and jeopardize the future of our entire profession. In the last 4 years alone, burn-out rates among physicians have increased by 25%. In a recent 2017 Medscape publication, burn-out rates in Critical Care physicians ranked in 9th place and Pediatricians ranked 13th among 27 subspecialties. Astonishingly, over 50% of the participants reported burn-out symptoms, with clear race and gender disparities. While men generally report higher burn-out rates than women, it is important to emphasize that response rates from women in these surveys were notoriously low and may not represent the complete picture. These numbers are even more dismal for tenured academic faculty at research-extensive universities. In this group, emotional exhaustion (i.e. high burn-out) is reported at 35% with a clear association with age and lower burn-out levels in the older tenured faculty. While no gender or racial/ethnic differences were found in this particular group, higher levels of burn-out were identified in individuals with financial responsibilities beyond a spouse and child. While it is comforting to note the increasing public interest and research activities in this field, successful approaches to ameliorate the burden and consequences of physician burn-out are still inadequately developed. Academic centers increasingly offer some type of work-life balance program to their employees but, unfortunately, these programs are frequently adopted from corporate business models and remain largely ineffective in the academic environment. It should be evident to most administrators that the stressors of academic clinicians and scientists substantially differ from those of corporate employees. Based on these observations and over 75 years of combined experience in academic medicine amongst the three editors of this Research Topic, we collected 26 manuscripts from 22 authors at different career stages and different genders, ethnicities, marital status and subspecialties to identify and stratify common and specific stressors and therapeutic approaches to ameliorate burn-out and achieve work-life balance in academic medicine. We are confident that each reader will identify with at least one, if not several, of the authors’ opinions, experiences and approaches to attain greater work-life balance and thereby avoid the consequences of burn-out in modern academic medicine

Clinical Profile Associated with Adverse Childhood Experiences: The Advent of Nervous System Dysregulation

Background: We report the prevalence of children with multiple medical symptoms in a pediatric neurology clinic, describe their symptom profiles, and explore their association with adverse childhood experiences (ACEs). Methods: We retrospectively reviewed 100 consecutive patients from an outpatient pediatric neurology clinic. Patients were included if they were ≥5 years old and reported ≥4 symptoms that were unexplained for ≥3-months. Symptom profiles across six functional domains were recorded: (1) executive dysfunction, (2) sleep disturbances, (3) autonomic dysregulation, (4) somatization, (5) digestive symptoms, and (6) emotional dysregulation. ACEs were scored for all patients. Results: Seventeen patients reported ≥4 medical symptoms. Somatization, sleep disturbances, and emotional dysregulation occurred in 100% patients, with executive dysfunction (94%), autonomic dysregulation (76%), and digestive problems (71%) in the majority. Forty-two children reported ≥1 ACE, but children with ≥4 symptoms were more likely to report ACEs compared to other children (88% vs. 33%; p < 0.0001) and had a higher median total ACE score (3 vs. 1; p < 0.001). Conclusions: Children with multiple medical symptoms should be screened for potential exposure to ACEs. A clinical profile of symptoms across multiple functional domains suggests putative neurobiological mechanisms involving stress and nervous system dysregulation that require further study

Can translational social neuroscience research offer insights to mitigate structural racism in America?

Social isolation and conflict due to structural racism may result in human suffering and loneliness across the lifespan. Given the rising prevalence of these problems in America, combined with disruptions experienced during the COVID-19 pandemic, the neurobiology of affiliative behaviors may offer practical solutions to the pressing challenges associated with structural racism. Controlled experiments across species demonstrate that social connections are critical to survival, although strengthening individual resilience is insufficient to address the magnitude and impact of structural racism. In contrast, the multi-level construct of social resilience, defined by the power of groups to cultivate, engage in, and sustain positive relationships that endure and recuperate from social adversities, offers unique insights that may have greater impact, reach, and durability than individual-level interventions. Here, we review the putative social resilience-enhancing interventions and, when available, their biological mediators, with the hope to stimulate discovery of novel approaches to mitigate structural racism. We will first explore the social neuroscience principles underlying psychotherapy and other psychiatric interventions. Then, we will explore translational efforts across species to tailor treatments that increase social resilience, with context and cultural sensitivity in mind. Finally, we will conclude with some practical future directions for understudied areas that may be essential for progress in biological psychiatry, including ethical ways to increase representation in research and developing social paradigms that inform dynamics toward or away from socially resilient outcomes