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Detecting pediatric delirium in critically ill children is important. The Sophia Observation withdrawal Symptoms and Delirium scale (SOS-PD) is a tool for assessing both pediatric delirium and iatrogenic withdrawal symptoms and contains a question for parents to assist in detecting pediatric delirium. The aim was to translate the Japanese SOS-PD and to perform a cross-culture validation of the J-SOS-PD pediatric delirium dimension while confirming the accuracy of family assessments of pediatric delirium. The translation was undertaken with the internationally established forward- backward translation method. Pediatric delirium was simultaneously evaluated and compared between psychiatric diagnoses based on assessment by a pediatric intensivist and the Japanese version of the SOS-PD as evaluated by PICU researchers. We evaluated the criterion validity (sensitivity and specificity), cut-off point using a receiver operating characteristic (ROC) curve, and reliability with Cohen's κ coefficient and intraclass correlation coefficients (ICC). A total of 125 independent assessments were performed in 67 children with a median age of 15 (IQR 5, 54) months and with a pediatric delirium-positive rate of 30% based on psychiatric evaluation. Based on the ROC curve analysis, the cut-off point of 4 was the most appropriate within the original scale and the Japanese SOS-PD version showed high sensitivity (0.92, 95% CI 0.84-1.00) and specificity (0.97, 95% CI 0.94-1.00) at a cut-off point of 4 and high reliability within the researcher assessments (κ = 0.95). We also verified family assessments of pediatric delirium as showing high sensitivity (0.90) and specificity (0.89) over 36 assessments. The Japanese version of the SOS-PD shows a high accuracy similar to the original. Moreover, we revealed high accuracy in family perception of pediatric delirium that could promote family presence in PICU settings.

Surgical intervention creates reactive oxygen species through diverse molecular mechanisms, including direct stimulation of immune-mediated inflammation necessary for wound healing. However, dysregulation of redox homeostasis in surgical patients overwhelms the endogenous defense system, slowing the healing process and damaging organs. We broadly surveyed reactive oxygen species that result from surgical interventions and the endogenous and/or exogenous antioxidants that control them. This study assimilates current reports on surgical sources of reactive oxygen and nitrogen species along with literature reports on the effects of endogenous and exogenous antioxidants in human, animal, and clinical settings. Although exogenous antioxidants are generally beneficial, endogenous antioxidant systems account for over 80% of total activity, varying based on patient age, sex, and health or co-morbidity status, especially in smokers, the diabetic, and the obese. Supplementation of exogenous compounds for support in surgical patients is thus theoretically beneficial, but a lack of persuasive clinical evidence has left this potential patient support strategy without clear guidelines. A more thorough understanding of the mechanisms of exogenous antioxidants in patients with compromised health statuses and pharmacokinetic profiling may increase the utility of such support in both the operating and recovery rooms.

Background Although the combination of rehabilitation and nutrition may be important for the prevention of intensive care unit (ICU)-acquired weakness, a protocolized intervention of this combination has not yet been reported. We herein developed an original combined protocol and evaluated its efficacy. Methods In this single-center historical control study, we enrolled adult patients admitted to the ICU. Patients in the control group received standard care, while those in the intervention group received the protocol-based intervention. The ICU mobility scale was used to set goals for early mobilization and a neuromuscular electrical stimulation was employed when patients were unable to stand. The nutritional status was assessed for nutritional therapy, and target calorie delivery was set at 20 or 30 kcal/kg/day and target protein delivery at 1.8 g/kg/day in the intervention group. The primary endpoint was a decrease in femoral muscle volume in 10 days assessed by computed tomography. Results Forty-five patients in the control group and 56 in the intervention group were included in the analysis. Femoral muscle volume loss was significantly lower in the intervention group (11.6 vs 14.5%, p  = 0.03). The absolute risk difference was 2.9% (95% CI 0.1–5.6%). Early mobilization to a sitting position by day 10 was achieved earlier ( p  = 0.03), and mean calorie delivery (20.1 vs. 16.8 kcal/kg/day, p  = 0.01) and mean protein delivery (1.4 vs. 0.8 g/kg/day, p  < 0.01) were higher in the intervention group. Conclusion The protocolized intervention, combining early mobilization and high-protein nutrition, contributed to the achievement of treatment goals and prevention of femoral muscle volume loss. Trial registration number The present study is registered at the University Hospital Medical Information Network-clinical trials registry (UMIN000040290, Registration date: May 7, 2020).

Background This systematic review and meta-analysis of randomized clinical trials aimed to investigate the efficacy of early mobilization among critically ill adult patients. Methods We searched CENTRAL, MEDLINE, and Igaku-Chuo-Zasshi (a Japanese bibliographic database) databases until April 2019 and included randomized control trials to compare early mobilization started within 1 week of intensive care unit (ICU) admission and earlier-than-usual care with the usual care or mobilization initiated later than the intervention. Two authors independently extracted the data of the included studies and assessed their quality. The primary outcomes were in-hospital mortality, length of ICU/hospital stay, and health-related quality of life (QOL). Results Among 1085 titles/abstracts screened, 11 studies (including 1322 patients) were included in the meta-analysis, which was conducted using the random-effects model. The pooled relative risk for in-hospital mortality comparing early mobilization to usual care (control) was 1.12 (95% CI [confidence interval]: 0.80 to 1.58, I 2 = 0%). The pooled mean differences for duration of ICU and hospital stay were -1.54 (95% CI: -3.33 to 0.25, I 2 = 90%) and -2.86 (95% CI: -5.51 to -0.21, I 2 = 85%), respectively. The pooled mean differences at 6 months post-discharge, as measured by the Short Form 36-Item Health Survey and Euro-QOL EQ-5D, were 4.65 (95% CI: -16.13 to 25.43, I 2 = 86%) for physical functioning and 0.29 (95% CI: -11.19 to 11.78, I 2 = 66%) for the visual analog scale. Conclusions Our study indicated no apparent differences between early mobilization and usual care in terms of in-hospital mortality and health-related QOL. Detailed larger studies are warranted to evaluate the impact of early mobilization on in-hospital mortality and health-related QOL in critically ill patients. Trial registration PROSPERO (identifier CRD42019139265 )

In some regions, critically ill pediatric and adult patients are cared for in the same intensive care unit, complicating pain assessment due to mixed age groups. To address this, it is essential to use pain scales that are applicable to a wide age range. The Critical-Care Pain Observation Tool (CPOT) was developed to assess pain in both intubated and non-intubated adult patients. However, its applicability in pediatric patients has not been confirmed. The purpose of this study was to evaluate CPOT for critically ill pediatric patients. We conducted a prospective observational study in an eight-bed open PICU from January 2022 to March 2023. Three research nurses independently assessed pain using CPOT, the Face, Legs, Activity, Cry, Consolability (FLACC) scale, and an Observational Visual Analog Scale (VAS obs). Criterion-related and construct validity were examined using Spearman's rank correlation coefficients between CPOT, VAS obs, and FLACC. Diagnostic performance was evaluated via ROC analysis using a FLACC score ≥ 4 as the reference. CPOT scores with and without medical interventions were compared using the Mann-Whitney U test, and inter-rater reliability was assessed with Cohen's weighted κ. Ninety-one patients were observed 165 times. CPOT strongly correlated with VAS obs (Spearman's ρ =  0.87, p <  0.01) and FLACC (Spearman's ρ =  0.84, p <  0.01). At a CPOT cut-off score of 3, sensitivity was 100% and specificity was 96.7%. CPOT effectively reflected pain levels during medical interventions (p <  0.01), and inter-rater reliability was high (weighted κ =  0.89, 95% CI: 0.799-0.941). This study suggests that CPOT may be a useful tool for pain assessment in pediatric patients.

This study aims to translate the Healthy Work Environment Assessment Tool (HWE-AT) into Japanese and evaluate its validity and reliability. The authors followed the guidelines for scale translation, adaptation, and validation in cross-cultural healthcare research. After translation and back-translation, a series of pilot studies were conducted to assess comprehensibility. Subsequently, an expert panel established the content validity. Content validity was calculated using the content validity index (CVI). Finally, we verified the construct validity and calculated the test-retest reliability. The updated HWE-AT achieved sufficient comprehensibility after conducting the two pilot tests. Content validity was calculated using the scale-level CVI/average and all the items were 1.00. The content validity indices CFI and RMSEA were 0.918 and 0.082, respectively. Intraclass correlation coefficients for all dimensions ranged from 0.618 to 0.903, indicating acceptable test-retest reliability. Our findings suggest that the Japanese version of the HWE-AT has good validity and reliability.

Background\\nPediatric patients, especially in the preverbal stage, cannot self-report intensity of pain therefore several validated observational tools, including the Face, Legs, Activity, Cry, Consolability (FLACC) Behavioral Scale, have been used as a benchmark to evaluate pediatric pain. Unfortunately, this scale is currently unavailable in Japanese, precluding its widespread use in Japanese hospitals.\\n\\nObjectives\\nTo translate and verify the validity and reliability of the Japanese version of the FLACC Behavioral Scale.\\n\\nMethod\\nBack-translation was first conducted by eight medical researchers, then an available sample of patients at the University of Tsukuba Pediatric Intensive Care Unit (from May 2017 to August 2017) was enrolled in a clinical study. Two researchers evaluated the validity of the translated FLACC Behavioral Scale by weighted kappa coefficient and intraclass correlation coefficients (ICC). Observational pain was simultaneously measured by the visual analog scale (VAS obs) and reliability was evaluated by correlation analysis.\\n\\nResult\\nThe original author approved the translation. For the clinical study, a total of 121 observations were obtained from 24 pediatric patients. Agreement between observers was highly correlated for each of the FLACC categories (Face: κ = 0.85, Leg: κ = 0.74, Activity: κ = 0.89, Cry: κ = 0.93, Consolability: κ = 0.93) as well as the total score (Total: κ = 0.95,). Correlation analysis demonstrated a good criterion validation between the FLACC scale and the VAS obs. (r = 0.96)\\n\\nConclusion\\nOur Japanese version of the FLACC Behavioral Scale shows high validity and reliability.

The World Health Organization included burnout syndrome criteria that reduce both professional quality of life and work satisfaction in its 11th Revision of the International Classification of Diseases in 2019 while nursing bodies have issued action calls to prevent burnout syndrome. Despite this, the effect of social factors, personality traits and cross-interaction on professional quality of life is still unclear. To reveal the association between ethical climate, personal trait and professional quality of life. An online survey of registered nurses working in adult, pediatric or both ICUs. We used the ten-item personality measure based on The Big Five theory and Type-D personality Scale-14 then measured the ethical climate with the Hospital Ethical Climate Survey and the professional domains of burnout syndrome, secondary traumatic stress and compassion satisfaction by the Professional Quality of Life Scale Version 5 simultaneously. Multivariate analysis confirmed the triangular association of hospital ethical climate, personality traits and professional quality of life. We enrolled 310 participants from September 2019 to February 2020. Mean age was 33.1 years (± 5.9) and about 70% were female. In the multivariate analysis, neuroticism (p = 0.03, p = 0.01) and Type D personality (both of p<0.01) were associated with burnout syndrome and secondary traumatic stress while agreeableness (p<0.01) was associated with secondary traumatic stress. Conversely, extraversion (p = 0.01), agreeableness (p<0.01) and openness (p<0.01) were associated with compassion satisfaction. We also observed interactions between hospital ethical climate and conscientiousness (p = 0.01) for burnout syndrome and secondary traumatic stress. Neuroticism was related to (p<0.01) BOS and compassion satisfaction while Type D personality (p<0.01) correlated with burnout syndrome and secondary traumatic stress. Hospital ethical climate strongly affects professional quality of life in nurses with specific personality traits. Therefore, it is important to maintain an ethical hospital climate, considering individual personalities to prevent burnout syndrome.

Despite global consensus on the importance of screening pediatric delirium, correlations between pediatric delirium during acute brain injury and adult delirium are unclear. Therefore, we hypothesized that similar pediatric biomarkers reflect acute brain injury as in adult delirium. We observed pediatric cardiac surgery patients from neonatal age to 18 years, who were admitted to our pediatric intensive care unit after cardiovascular operations between October 2019 to June 2020, up to post-operative day 3 (4 days total). We recorded age, sex, risk score (Risk Adjustment in Congenital Heart Surgery [RACHS-1]), midazolam/dexmedetomidine/fentanyl dosage, and pediatric Sequential Organ Failure Assessment (pSOFA). Richmond Agitation-Sedation Scale (RASS), Cornell Assessment of Pediatric Delirium (CAPD), Face, Leg, Activity, Consolability (FLACC) behavioral scale, and Withdrawal Assessment Tool (WAT-1) scales were used and serum sampling for neuron specific enolase (NSE) was conducted. Consciousness status was considered hierarchical (coma > delirium > normal) and associations between conscious status and NSE were conducted by hierarchical Bayesian modeling. We analyzed 134 data points from 40 patients (median age 12 months). In the multi-regression model, NSE was positively associated with coma [posterior odds ratio (OR) = 1.1, 95% credible interval (CrI) 1.01–1.19] while pSOFA [posterior OR = 1.63, 95% CrI 1.17–2.5], midazolam [posterior OR = 1.02, 95% CrI 1.01–1.04], and dexmedetomidine [posterior OR = 9.52, 95% CrI 1.02–108.85] were also associated. We also evaluated consciousness state probability at each NSE concentration and confirmed both that consciousness was hierarchically sorted and CAPD scores were also associated with NSE [posterior OR = 1.32, 95% CrI 1.09–1.58]. “Eye contact” (r = 0.55) was the most correlated component with NSE within the pain, withdrawal syndrome, and PD items. PD within the hierarchy of consciousness (coma, delirium, normal) and CAPD scores are associated with brain injury marker levels. Using pediatric delirium assessment tools for monitoring brain injury, especially eye contact, is a reliable method for observing PD.

Down syndrome (DS) is frequently comorbid with congenital heart disease and has recently been shown to reduce the sedative effect of benzodiazepine (BDZ)-class anesthesia but this effect in a clinical setting has not been studied. Therefore, this study compared midazolam sedation after heart surgery in DS and normal children. We retrospectively reviewed patient records in our pediatric intensive care unit (PICU) of pediatric cardiovascular operations between March 2015 and March 2018. We selected five days of continuous post-operative data just after termination of muscle relaxants. Midazolam sedation was estimated by Bayesian inference for generalized linear mixed models. We enrolled 104 patients (average age 26 weeks) of which 16 (15%) had DS. DS patients had a high probability of receiving a higher midazolam dosage and dexmedetomidine dosage over the study period (probability = 0.99, probability = 0.97) while depth of sedation was not different in DS patients (probability = 0.35). Multi regression modeling included severity scores and demographic data showed DS decreases midazolam sedation compared with controls (posterior OR = 1.32, 95% CrI = 1.01–1.75). In conclusion, midazolam dosages should be carefully adjusted as DS significantly decreases midazolam sedative effect in pediatric heart surgery patients.