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ABSTRACT Objective: to analyze how the process of implementing an onco-hematology nursing service at a pediatric hospital in Rio de Janeiro took place. Methods: a historical, qualitative study. Sources included written and oral documents, produced through semi-structured interviews, carried out between August 2022 and February 2023 with nurses who worked on implementing the service, represented by 40 minutes, nine care protocols and eight reports from the hospital’s internal website. Results: nursing staff reorganization and investment in professional improvement, through courses and graduate courses, culminated in the establishment of protocols, committees and nursing indicators, which enabled the implementation of a service with quality and safety. Final considerations: the implementation of a nursing service in pediatric onco-hematology was successful and, while highlighting the importance of nursing, also delivered quality service to society, strengthening the Brazilian Health System. RESUMEN Objetivo: analizar cómo se desarrolló el proceso de implementación del servicio de enfermería de oncohematología en un hospital pediátrico de Río de Janeiro. Métodos: estudio histórico, cualitativo. Las fuentes incluyeron documentos escritos y orales, elaborados a partir de entrevistas semiestructuradas, realizadas entre agosto de 2022 y febrero de 2023 con enfermeros que trabajaron en la implementación del servicio, representados por 40 minutos, nueve protocolos de atención y ocho informes del sitio web interno del hospital. Resultados: la reorganización del equipo de enfermería y la inversión en superación profesional, a través de cursos y posgrados, culminaron en el establecimiento de protocolos, comités e indicadores de enfermería, que permitieron implementar un servicio con calidad y seguridad. Consideraciones finales: la implementación del servicio de enfermería en oncohematología pediátrica fue exitosa y, al tiempo que destacó la importancia de la enfermería, también entregó un servicio de calidad a la sociedad, fortaleciendo el Sistema Único de Salud. RESUMO Objetivo: analisar como se deu o processo de implantação do serviço de enfermagem em onco-hematologia de um hospital pediátrico no Rio de Janeiro. Métodos: estudo histórico, qualitativo. Fontes incluíram documentos escritos e orais, produzidos por entrevistas semiestruturadas, realizadas entre agosto de 2022 e fevereiro de 2023 com enfermeiras que atuaram na implantação do serviço, representados por 40 atas, nove protocolos assistenciais e oito reportagens do site interno do hospital. Resultados: a reorganização da equipe de enfermagem e o investimento no aprimoramento profissional, por meio de cursos e pós-graduações, culminaram na instituição de protocolos, comissões e indicadores de enfermagem, os quais possibilitaram a implantação de um serviço com qualidade e segurança. Considerações finais: a implantação do serviço de enfermagem em onco-hematologia pediátrica foi exitosa e, ao tempo que evidenciou a importância da enfermagem, também entregou à sociedade um serviço de qualidade, fortalecendo o Sistema Único de Saúde.

ObjectivesTo develop evidence-based recommendations for clinicians caring for children (including infants, school-aged children, and adolescents) with septic shock and other sepsis-associated organ dysfunction.DesignA panel of 49 international experts, representing 12 international organizations, as well as three methodologists and three public members was convened. Panel members assembled at key international meetings (for those panel members attending the conference), and a stand-alone meeting was held for all panel members in November 2018. A formal conflict-of-interest policy was developed at the onset of the process and enforced throughout. Teleconferences and electronic-based discussion among the chairs, co-chairs, methodologists, and group heads, as well as within subgroups, served as an integral part of the guideline development process.MethodsThe panel consisted of six subgroups: recognition and management of infection, hemodynamics and resuscitation, ventilation, endocrine and metabolic therapies, adjunctive therapies, and research priorities. We conducted a systematic review for each Population, Intervention, Control, and Outcomes question to identify the best available evidence, statistically summarized the evidence, and then assessed the quality of evidence using the Grading of Recommendations Assessment, Development, and Evaluation approach. We used the evidence-to-decision framework to formulate recommendations as strong or weak, or as a best practice statement. In addition, “in our practice” statements were included when evidence was inconclusive to issue a recommendation, but the panel felt that some guidance based on practice patterns may be appropriate.ResultsThe panel provided 77 statements on the management and resuscitation of children with septic shock and other sepsis-associated organ dysfunction. Overall, six were strong recommendations, 49 were weak recommendations, and nine were best-practice statements. For 13 questions, no recommendations could be made; but, for 10 of these, “in our practice” statements were provided. In addition, 52 research priorities were identified.ConclusionsA large cohort of international experts was able to achieve consensus regarding many recommendations for the best care of children with sepsis, acknowledging that most aspects of care had relatively low quality of evidence resulting in the frequent issuance of weak recommendations. Despite this challenge, these recommendations regarding the management of children with septic shock and other sepsis-associated organ dysfunction provide a foundation for consistent care to improve outcomes and inform future research.

Table 1 Summary of the main conditions reported in children and the perinatal period and deaths where delayed presentation was considered by the reporting paediatrician to be a contributing factor n Top 5 delayed diagnoses reported  Diabetes mellitus (diabetic ketoacidosis) 44 (23)  Sepsis 21  Child protection 14  Malignancy 8  Appendicitis 6 Delayed perinatal presentations  Pregnant women presenting late in labour 2  Hypoxic ischaemic encephalopathy 1  Unbooked pregnancy resulting in adverse outcomes 1  Poor feeding after early hospital discharge 2  Dehydration following poor feeding 4 Reported deaths associated with delayed presentation  Sepsis 3  New diagnosis of malignancy 3  Cause not reported 2  New diagnosis of metabolic disease 1 Of the paediatricians working on hospital wards and in clinics, 18% (178 of 997) had also witnessed delayed presentations. Neonatologists’ concerns included late presentations during labour resulting in adverse maternal/neonatal outcomes and early hospital discharges after birth due to COVID-19 concerns before feeding had been established and infants then returning with feeding difficulties and severe dehydration (table 1). Elsewhere, others have raised concerns about declining immunisation rates,4 and the mental health and well-being of children during lockdown.5 While the information collected in the survey was subjective and based on the opinion of individual paediatricians, and although we do not have baseline data for comparison, our findings highlight an urgent need to improve public health messaging for parents, which until recently instructed everyone to stay at home.

The purpose of the study was to implement and prospectively evaluate the outcomes of a rapid genomic diagnosis program at two pediatric tertiary centers. Rapid singleton whole-exome sequencing (rWES) was performed in acutely unwell pediatric patients with suspected monogenic disorders. Laboratory and clinical barriers to implementation were addressed through continuous multidisciplinary review of process parameters. Diagnostic and clinical utility and cost-effectiveness of rWES were assessed. Of 40 enrolled patients, 21 (52.5%) received a diagnosis, with median time to report of 16 days (range 9–109 days). A result was provided during the first hospital admission in 28 of 36 inpatients (78%). Clinical management changed in 12 of the 21 diagnosed patients (57%), including the provision of lifesaving treatment, avoidance of invasive biopsies, and palliative care guidance. The cost per diagnosis was AU$13,388 (US$10,453). Additional cost savings from avoidance of planned tests and procedures and reduced length of stay are estimated to be around AU$543,178 (US$424,101). The clear relative advantage of rWES, joint clinical and laboratory leadership, and the creation of a multidisciplinary “rapid team” were key to successful implementation. Rapid genomic testing in acute pediatrics is not only feasible but also cost-effective, and has high diagnostic and clinical utility. It requires a whole-of-system approach for successful implementation.

Abstract The last 2 decades have seen growing recognition of the need to appropriately identify and treat children with osteoporotic fractures. This focus stems from important advances in our understanding of the genetic basis of bone fragility, the natural history and predictors of fractures in chronic conditions, the use of bone-active medications in children, and the inclusion of bone health screening into clinical guidelines for high-risk populations. Given the historic focus on bone densitometry in this setting, the International Society for Clinical Densitometry published revised criteria in 2013 to define osteoporosis in the young, oriented towards prevention of overdiagnosis given the high frequency of extremity fractures during the growing years. This definition has been successful in avoiding an inappropriate diagnosis of osteoporosis in healthy children who sustain long bone fractures during play. However, its emphasis on the number of long bone fractures plus a concomitant bone mineral density (BMD) threshold ≤ −2.0, without consideration for long bone fracture characteristics (eg, skeletal site, radiographic features) or the clinical context (eg, known fracture risk in serious illnesses or physical-radiographic stigmata of osteoporosis), inappropriately misses clinically relevant bone fragility in some children. In this perspective, we propose a new approach to the definition and diagnosis of osteoporosis in children, one that balances the role of BMD in the pediatric fracture assessment with other important clinical features, including fracture characteristics, the clinical context and, where appropriate, the need to define the underlying genetic etiology as far as possible.

In the past 20 years, the number of hospitalists in the United States has grown from a few hundred to more than 50,000. Although challenges remain, many stars have aligned to enable the model to thrive and contribute to high-quality, efficient inpatient care. Twenty years ago, we described the emergence of a new type of specialist that we called a “hospitalist.” 1 Since then, the number of hospitalists has grown from a few hundred to more than 50,000 (see graph) — making this new field substantially larger than any subspecialty of internal medicine (the largest of which is cardiology, with 22,000 physicians), about the same size as pediatrics (55,000), and in fact larger than any specialty except general internal medicine (109,000) and family medicine (107,000). Approximately 75% of U.S. hospitals, including all highly ranked academic health centers, now have hospitalists. The field’s rapid growth . . .

Availability of clinical genomic sequencing (CGS) has generated questions about the value of genome and exome sequencing as a diagnostic tool. Analysis of reported CGS application can inform uptake and direct further research. This scoping literature review aims to synthesize evidence on the clinical and economic impact of CGS. PubMed, Embase, and Cochrane were searched for peer-reviewed articles published between 2009 and 2017 on diagnostic CGS for infant and pediatric patients. Articles were classified according to sample size and whether economic evaluation was a primary research objective. Data on patient characteristics, clinical setting, and outcomes were extracted and narratively synthesized. Of 171 included articles, 131 were case reports, 40 were aggregate analyses, and 4 had a primary economic evaluation aim. Diagnostic yield was the only consistently reported outcome. Median diagnostic yield in aggregate analyses was 33.2% but varied by broad clinical categories and test type. Reported CGS use has rapidly increased and spans diverse clinical settings and patient phenotypes. Economic evaluations support the cost-saving potential of diagnostic CGS. Multidisciplinary implementation research, including more robust outcome measurement and economic evaluation, is needed to demonstrate clinical utility and cost-effectiveness of CGS.

Background The presence of women in decision-making positions, such as on editorial committees of biomedical journals, is not the same as that of men. This paper analyzes the gender composition of editorial committees (EBMs) and editors-in-chief (ECs) positions of pediatric journals. Methods The gender of EBMs and ECs of 125 journals classified in the pediatrics area of the Journal Citation Report (JCR) was analyzed. The following indicators were calculated: gender distribution of ECs and EBMs by journal, publisher, subject speciality, country, quartile of the journal in JCR and country of affiliation of the members. Results The total number of EBMs was 4242. The distribution by sex of the ECs was 19.44% women and 80.56% men, while that of the EBMs were 33.05% women and 66.95% men. Twenty journals exhibited a greater representation of women than of men, and in four there was parity. Journals with greater participation of women specialized in nursing and physical therapy and were related to nutrition (lactation and breastfeeding). Conclusions Only one-fifth of ECs and one-third of EBMs are females. Women’s participation is higher in journals related to nursing, physical and occupational therapy, and nutrition. The United States has the highest number of EBMs, followed by the European Union. Impact Only one-fifth of Editors-in-chief in pediatrics journals are female. Only one-third of Editorial Board Members in pediatrics journals are female. Women’s participation is higher in editorials committees in pediatrics journals related to nursing, physical and occupational therapy, and nutrition. Medical and pediatric associations and societies must work together to eliminate the disparities that exist between women and men. Achieving gender equity and empowering all women is one of the World Health Organization’s Sustainable Development Goals.

The purpose of this review is to provide an update on the changing face of paediatric type 1 diabetes and type 2 diabetes. Paediatric diabetes is on the rise, with extensive research dedicated to understanding its pathophysiology, comorbidities and complications. As obesity continues to increase among all youth, differentiating between type 1 diabetes and type 2 diabetes has become increasingly difficult but remains important for optimising treatment, anticipating complications and predicting disease risk. Novel treatments are emerging, with the ultimate goal being to achieve glycaemic control, limit weight gain, improve quality of life and reduce comorbidities. In this review, we focus on updates regarding the epidemiology, clinical presentation, comorbidities and complications of paediatric type 1 diabetes and type 2 diabetes and conclude with current and emerging treatments.

Pediatric (PARDS) and neonatal (NARDS) acute respiratory distress syndrome have different age-specific characteristics and definitions. Trials on surfactant for ARDS in children and neonates have been performed well before the PARDS and NARDS definitions and yielded conflicting results. This is mainly due to heterogeneity in study design reflecting historic lack of pathobiology knowledge. We reviewed the available clinical and preclinical data to create an expert consensus aiming to inform future research steps and advance the knowledge in this area. Eight trials investigated the use of surfactant for ARDS in children and ten in neonates, respectively. There were improvements in oxygenation (7/8 trials in children, 7/10 in neonates) and mortality (3/8 trials in children, 1/10 in neonates) improved. Trials were heterogeneous for patients’ characteristics, surfactant type and administration strategy. Key pathobiological concepts were missed in study design. Consensus with strong agreement was reached on four statements: There are sufficient preclinical and clinical data to support targeted research on surfactant therapies for PARDS and NARDS. Studies should be performed according to the currently available definitions and considering recent pathobiology knowledge. PARDS and NARDS should be considered as syndromes and should be pre-clinically studied according to key characteristics, such as direct or indirect (primary or secondary) nature, clinical severity, infectious or non-infectious origin or patients’ age. Explanatory should be preferred over pragmatic design for future trials on PARDS and NARDS. Different clinical outcomes need to be chosen for PARDS and NARDS, according to the trial phase and design, trigger type, severity class and/or surfactant treatment policy . We advocate for further well-designed preclinical and clinical studies to investigate the use of surfactant for PARDS and NARDS following these principles.