See also editorial on page [1195][1] and at [www.cmaj.ca/lookup/doi/10.1503/cmaj.141207][2] The Canadian health care system is undergoing substantial transformation to meet the needs of the rising number of adults, particularly older adults, with complex chronic conditions. Provinces are planning
Abstract Background While children with medical complexity (CMC) are recognized as an emerging and unique cohort, end of life remains poorly understood and little is known about illness trajectory, decision making and communication experiences for this group of patients and their families. Objectives This scoping review aimed to describe existing literature on the characteristics of end of life in CMC. Design/Methods The study was conducted in accordance with the Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR). Electronic databases (MEDLINE, CINAHL, PsycINFO, Scopus, Embase) were searched up to June 2021. Studies reporting children, adolescents and young adults who were at end of life and fulfilled the definitional framework of medical complexity by Cohen et al were included by two independent reviewers. Data on study aims, design, methods, outcome measures and key findings were extracted, followed by quantitative and qualitative analysis of the results. Results Of 1535 publications initially identified, 23 studies were included. In terms of study characteristics, 20 (87.0%) studies were quantitative, 15 (65.2%) were published from 2015 to 2021 and 14 (70.0%) originated from the USA. Study outcomes were categorized into 5 main groups: (1) Place of death (30.8%), (2) Health care use (23.1%), (3) Interventions received or withdrawn (17.9%) (4) Decision making and communication (12.8%) and (5) Others (15.4%). These outcomes were found to be associated with sociodemographic factors and CMC diagnostic categories. Majority of CMC deaths occurred in hospitals and the mean proportion of hospital deaths reported was 68.8% (33.5% to 91.9%). Studies evaluated health care utilization at end of life in various settings including hospice, home care, hospital and the intensive care unit. Interventions studied in this cohort included mechanical ventilation, cardiopulmonary resuscitation, hemodialysis, procedures and medication use. Studies reported that CMC were subjected to more intensive interventions when compared to non-CMC. The 2 main themes which emerged from qualitative studies were that of advance care planning experiences and the unique end of life experiences of CMC and their families. Conclusion This scoping review highlighted the unique characteristics of end of life in CMC and outlined the emerging body of literature as well as knowledge gaps on this topic. A better understanding of this cohort of CMC would serve to inform clinical practice, service development and future research opportunities.
Children with symptoms and signs of constipation are commonly assessed in pediatric emergency departments (EDs). Little is known about their outcome following the ED visit.To describe the clinical characteristics of children presenting to the ED with constipation and the ED interventions; to measure short-term symptom resolution at 48 hours and 7 days after the ED visit; and to identify predictive factors associated with poor symptom resolution at 48 hours and 7 days after the ED visit.Cohort study conducted between July 10, 1997, and September 10, 1997, in a tertiary care pediatric hospital ED. All children (aged 1-18 years) with idiopathic constipation were included. Constipation was diagnosed if there were at least 2 of the following: abdominal pain, infrequent bowel movements, hard feces, fecal soiling, pain on defecation, and/or clinical evidence of excessively retained feces. Data on the presenting symptoms, signs, and ED treatment plan were collected on study enrollment and then in 2 standardized 10-minute telephone interviews at 48 hours and 7 days after the ED visit. At each follow-up, patient disposition was measured and dichotomized based on symptom resolution to "improved" vs "not improved." The presenting features and ED management were compared between groups using chi(2) analyses and t tests.Consent and full questionnaire completion was obtained in 102 children. The mean + SD age was 6.5 + 3.8 years; 47 (46%) were male. The predominant presenting symptom was abdominal pain (83 [81%]); the most frequent sign was palpable abdominal stool (67 [66%]). A high-fiber diet (75 [74%]) and mineral oil (48 [47%]) were prescribed most frequently. Enemas were given to 64 (63%) of the children. Improvement was found in 32 (31%) of the children at 48 hours and in the majority at 7 days (77 [75%]). Risk factors for poor symptom resolution at both 48 hours and 1 week included: female sex (odds ratio [OR] = 2.6; 95% confidence interval [CI] = 1.0 6.6); history of recurrent abdominal pain (OR = 2.8; 95% CI = 1.2-6.5); duration of primary presenting symptom longer than 2 days (OR = 2.4; 95% CI = 1.0-6.4); and history of medical visits for the same symptom (OR = 2.3; 95% CI = 1.0-5.3). There was no difference in outcome based upon ED treatment (enema vs oral or no therapy) (OR = 1.0; 95% CI = 0.4-2.3).Most children with constipation evaluated in the ED have acute symptoms and rapid improvement, regardless of presentation characteristics or ED management. In this study, 4 risk factors for poor outcome were found consistently at 48 hours and 7 days. This subgroup of children deserve closer clinical attention. Emergency department therapy did not influence short-term symptom resolution. Further studies are warranted to examine the effects of therapy for constipation in the ED setting. Arch Pediatr Adolesc Med. 2000;154:1204-1208.
Heterotopic ossification (HO) is the formation of bone at extraskeletal sites. Over 60% of amputees injured by improvised explosive devices in the recent conflict in Afghanistan have developed HO, resulting in functional impairment. It is hypothesised that a key aetiological factor is the blast wave; however, other environmental and medical risk factors, which the casualties have been exposed to, have also been postulated. The suicide terrorist bombings in London in 2005 resulted in many blast-related casualties, many of whom were managed by the Royal London Hospital. This cohort of severely injured patients whose injuries also included trauma-related amputations shared some, but not all, of the risk factors identified in the military population. We reviewed these patients, in particular to assess the presence or absence of military-established risk factors for the formation of HO in these casualties.
Background Systemic glucocorticoids have been widely prescribed for use in infants and young children with acute viral bronchiolitis but the actual benefit of this intervention requires clarification. Objectives To systematically review the evidence on the effectiveness of systemic glucocorticoids for the treatment of infants and young children with acute viral bronchiolitis. Search methods Multiple strategies were incorporated to maximize identification of suitable studies. The following databases were searched: the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library Issue 3, 2003); MEDLINE (January 1966 to September 2003); Current Contents (1998 to 2000); EMBASE (January 1990 to September 2003); and Sci Search. Handsearches through cited references and contacts with experts were also used. Selection criteria Only randomised controlled trials (RCT) were eligible for inclusion. Studies were included if participants were diagnosed with acute viral bronchiolitis and treated with systemic (oral, intramuscular or intravenous) corticosteroids. Three reviewers independently selected potentially relevant articles. Four reviewers evaluated these studies, determined eligibility and assessed the methodological quality of each RCT. Data collection and analysis The primary outcome of interest was length of hospital stay (LOS). Secondary outcomes were: respiratory rate, haemoglobin oxygen saturation, and hospital admission and revisit rates. Data were extracted independently by the four reviewers and the results compiled and compared. Two reviewers reassessed studies to clarify points of discrepancy in the data extraction and database entry processes. Missing data were requested from the authors or calculated from other data presented in the study report. Main results There was complete agreement on the inclusion of 13 trials and the exclusion of five studies. Two main study recruitment groups were identified: a) infants and young children within the first 48 hours of hospitalisation (10 trials), and b) outpatient infants and young children who were randomised from the emergency department and who may nor may not have required hospital admission (three trials). A total of 1,198 children aged 0 to 30 months were treated with the equivalent of 0.5 to 10 mg/kg of systemic prednisone for two to seven days. Outcomes of interest were not measured in each RCT. In the pooled analysis of seven trials, there was a decrease in LOS in treated children of 0.38 days (95% confidence interval (CI) ‐0.81 to 0.05), indicating no significant difference between treatment groups. In the pooled analysis of eight trials, the day three clinical score measured: a standard mean difference (SMD) of ‐0.20 (95% CI ‐0.73 to 0.32), indicating no difference between treatment groups. Subgroup analyses for base LOS and clinical score outcomes were performed on infants who were a) less than 12 months of age, b) all respiratory syncytial virus (RSV) positive, c) treated with less than 6 mg/kg of prednisone equivalent throughout the illness and d) first‐time wheezers. These were limited by the small number of studies in each subgroup. Hospital admission rates were examined in three trials and no difference was seen between treatment groups (odds ratio (OR) 1.05 (95% CI 0.23 to 4.87). Readmission rates were reported in six studies; with no significant differences between treatment groups. Hospital revisit rates were reported in three studies, with a significant difference between treatment groups reported in one study only. The respiratory rate and haemoglobin oxygen saturation were reported descriptively in six RCTs; no differences were found between groups. Co‐interventions (oxygen, supportive fluids and bronchodilators) were used similarly between treatment groups in all RCTs. Authors' conclusions No benefits were found in either LOS or clinical score in infants and young children treated with systemic glucocorticoids as compared to placebo. There were no differences in these outcomes between treatment groups; either in the pooled analysis or in any of the sub analyses. Among the three studies evaluating hospital admission rates following the initial hospital visit there was no difference between treatment groups. There were no differences found in respiratory rate, haemoglobin oxygen saturation, hospital revisit or readmission rates. Subgroup analyses were significantly limited by the low number of studies in each comparison. Marked study heterogeneity and occasionally conflicting direction of benefit between trials suggests that these results should be interpreted with caution. Specific data on the harm of corticosteroid therapy in this patient population are lacking. Available evidence suggests that corticosteroid therapy is not of benefit in this patient group.
This review was withdrawn from The Cochrane Library, issue 1, 2008. The review authors were not able to update the review, due to lack of resources. New authors are being sought to update this review.
Bower P, Garralda E, Kramer T , et al. The treatment of child and adolescent mental health problems in primary care: a systematic review. Fam Pract2001 Aug; 18 : 373 –82 [OpenUrl][1][CrossRef][2][PubMed][3][Web of Science][4] QUESTION: What interventions are effective for treating mental health problems in children and adolescents in primary care? Studies were identified by searching Medline, PsycINFO, CINAHL, EMBASE/Excerpta Medica, and the Cochrane Controlled Trials Register in August 1999; scanning the reference lists of relevant studies; and contacting 34 subject experts and authors of included studies. Studies were selected if they were randomised controlled trials (RCTs), controlled before and after studies, or before and after studies without controls and participants were ≤18 years of age and were treated in primary care for mental health problems. Data were extracted on design, study population, sample size, and results. Educational studies involving the primary care team: 8 studies (1 RCT) were included. The RCT compared an introduction to the use of behaviour modification techniques (12 sessions) with … [1]: {openurl}?query=rft.jtitle%253DFamily%2BPractice%26rft.stitle%253DFam%2BPract%26rft.aulast%253DBower%26rft.auinit1%253DP.%26rft.volume%253D18%26rft.issue%253D4%26rft.spage%253D373%26rft.epage%253D382%26rft.atitle%253DThe%2Btreatment%2Bof%2Bchild%2Band%2Badolescent%2Bmental%2Bhealth%2Bproblems%2Bin%2Bprimary%2Bcare%253A%2Ba%2Bsystematic%2Breview%26rft_id%253Dinfo%253Adoi%252F10.1093%252Ffampra%252F18.4.373%26rft_id%253Dinfo%253Apmid%252F11477044%26rft.genre%253Darticle%26rft_val_fmt%253Dinfo%253Aofi%252Ffmt%253Akev%253Amtx%253Ajournal%26ctx_ver%253DZ39.88-2004%26url_ver%253DZ39.88-2004%26url_ctx_fmt%253Dinfo%253Aofi%252Ffmt%253Akev%253Amtx%253Actx [2]: /lookup/external-ref?access_num=10.1093/fampra/18.4.373&link_type=DOI [3]: /lookup/external-ref?access_num=11477044&link_type=MED&atom=%2Febmental%2F5%2F2%2F43.atom [4]: /lookup/external-ref?access_num=000170705700006&link_type=ISI
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