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Weatherly AJ, Wang L, Lindsell CJ, Martin EN, Hedden K, Heider C, Pearson JE, Betters KA. The Physical Abilities and Mobility Scale as a New Measure of Functional Progress in the PICU. J Pediatr Intensive Care 2024; 13:100-107. [PMID: 38571988 PMCID: PMC10987217 DOI: 10.1055/s-0041-1740215] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2021] [Accepted: 09/21/2021] [Indexed: 10/19/2022] Open
Abstract
Assessing functional motor changes and their relationship to discharge needs in the pediatric intensive care unit (PICU) population is difficult given challenges quantifying small functional gains with current tools. Therefore, we compared the Physical Abilities and Mobility Scale (PAMS) to the Functional Status Scale (FSS) in PICU patients to assess correlation and differences and association with discharge needs. This study was a retrospective chart review of all patients (2-18 years old) admitted to the PICU and cardiac PICU for over 9 months who received early mobility services, including PAMS and FSS scoring. Correlation between scales, relationship of scores to disposition, and logistic regression model of changes in PAMS in relation to disposition were determined. Data were obtained for 122 patients. PAMS and FSS scores strongly negatively correlated (Spearman's ρ = - 0.85), but with a nonlinear relationship, as the PAMS more readily differentiated among patients with higher functional status. The median FSS at discharge was 12.5 for those recommended an inpatient rehabilitation facility (IRF) ( n = 24), versus 9 for those recommended discharge home ( n = 83, Δ 3.5, 95% confidence interval [CI]: 1-6, around one-tenth of FSS scale). The corresponding median PAMS were 42 and 66 (Δ 24, 95% CI: 10-30, one-fourth of PAMS scale). Although not statistically significant, a logistic regression model was consistent with patients who showed modest change in PAMS across hospitalization but persistent deficits (PAMS < 60) were more likely to be recommended an IRF. The PAMS correlates to the FSS, but appears more sensitive to small functional changes, especially in higher functioning patients. It may be useful in prognosticating discharge needs.
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Affiliation(s)
- Allison J. Weatherly
- Department of Pediatrics, Division of Critical Care Medicine, Monroe Carell Jr. Children's Hospital at Vanderbilt, Nashville, Tennessee, United States
| | - Li Wang
- Department of Biostatistics, Vanderbilt University School of Medicine, Nashville, Tennessee, United States
| | - Christopher J. Lindsell
- Department of Biostatistics, Vanderbilt University School of Medicine, Nashville, Tennessee, United States
| | - Elizabeth N. Martin
- Department of Physical Medicine and Rehabilitation, Vanderbilt University Medical Center and Monroe Carell Jr. Children's Hospital at Vanderbilt, Nashville, Tennessee, United States
| | - Katherine Hedden
- Rehabilitation Services, Monroe Carell Jr. Children's Hospital at Vanderbilt, Nashville, Tennessee, United States
| | - Camille Heider
- Rehabilitation Services, Monroe Carell Jr. Children's Hospital at Vanderbilt, Nashville, Tennessee, United States
| | - Jennifer E. Pearson
- Rehabilitation Services, Monroe Carell Jr. Children's Hospital at Vanderbilt, Nashville, Tennessee, United States
| | - Kristina A. Betters
- Department of Pediatric Critical Care, Monroe Carell Jr. Children's Hospital at Vanderbilt, Nashville, Tennessee, United States
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McNamara CR, Kalinowski A, Horvat CM, Gaines BA, Richardson WM, Simon DW, Kochanek PM, Berger RP, Fink EL. New Functional Impairment After Hospital Discharge by Traumatic Brain Injury Mechanism in Younger Than 3 Years Old Admitted to the PICU in a Single Center Retrospective Study. Pediatr Crit Care Med 2024; 25:250-258. [PMID: 38088760 DOI: 10.1097/pcc.0000000000003417] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2024]
Abstract
OBJECTIVES Children who suffer traumatic brain injury (TBI) are at high risk of morbidity and mortality. We hypothesized that in patients with TBI, the abusive head trauma (AHT) mechanism vs. accidental TBI (aTBI) would be associated with higher frequency of new functional impairment between baseline and later follow-up. DESIGN Retrospective single center cohort study. SETTING AND PATIENTS Children younger than 3 years old admitted with TBI to the PICU at a level 1 trauma center between 2014 and 2019. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Patient characteristics, TBI mechanism, and Functional Status Scale (FSS) scores at baseline, hospital discharge, short-term (median, 10 mo [interquartile range 3-12 mo]), and long-term (median, 4 yr [3-6 yr]) postdischarge were abstracted from the electronic health record. New impairment was defined as an increase in FSS greater than 1 from baseline. Patients who died were assigned the highest score (30). Multivariable logistic regression was performed to determine the association between TBI mechanism with new impairment. Over 6 years, there were 460 TBI children (170 AHT, 290 aTBI), of which 13 with AHT and four with aTBI died. Frequency of new impairment by follow-up interval, in AHT vs. aTBI patients, were as follows: hospital discharge (42/157 [27%] vs. 27/286 [9%]; p < 0.001), short-term (42/153 [27%] vs. 26/259 [10%]; p < 0.001), and long-term (32/114 [28%] vs. 18/178 [10%]; p < 0.001). Sensory, communication, and motor domains were worse in AHT patients at the short- and long-term timepoint. On multivariable analysis, AHT mechanism was associated with greater odds (odds ratio [95% CI]) of poor outcome (death and new impairment) at hospital discharge (4.4 [2.2-8.9]), short-term (2.7 [1.5-4.9]), and long-term timepoints (2.4 [1.2-4.8]; p < 0.05). CONCLUSIONS In patients younger than 3 years old admitted to the PICU after TBI, the AHT mechanism-vs. aTBI-is associated with greater odds of poor outcome in the follow-up period through to ~5 years postdischarge. New impairment occurred in multiple domains and only AHT patients further declined in FSS over time.
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Affiliation(s)
- Caitlin R McNamara
- Department of Pediatric Critical Care Medicine, University of Pittsburgh, Pittsburgh, PA
| | - Anne Kalinowski
- Department of Pediatric Critical Care Medicine, University of Pittsburgh, Pittsburgh, PA
| | - Christopher M Horvat
- Department of Pediatric Critical Care Medicine, University of Pittsburgh, Pittsburgh, PA
| | - Barbara A Gaines
- Department of Pediatric Surgery, University of Pittsburgh, Pittsburgh, PA
| | - Ward M Richardson
- Department of Pediatric Surgery, University of Pittsburgh, Pittsburgh, PA
| | - Dennis W Simon
- Department of Pediatric Critical Care Medicine, University of Pittsburgh, Pittsburgh, PA
| | - Patrick M Kochanek
- Department of Pediatric Critical Care Medicine, University of Pittsburgh, Pittsburgh, PA
| | - Rachel P Berger
- Department of Child Advocacy, University of Pittsburgh, Pittsburgh, PA
| | - Ericka L Fink
- Department of Pediatric Critical Care Medicine, University of Pittsburgh, Pittsburgh, PA
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Feldman SJ, Beslow LA, Felling RJ, Malone LA, Waak M, Fraser S, Bakeer N, Lee JEM, Sherman V, Howard MM, Cavanaugh BA, Westmacott R, Jordan LC. Consensus-Based Evaluation of Outcome Measures in Pediatric Stroke Care: A Toolkit. Pediatr Neurol 2023; 141:118-132. [PMID: 36812698 PMCID: PMC10042484 DOI: 10.1016/j.pediatrneurol.2023.01.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/18/2022] [Revised: 01/08/2023] [Accepted: 01/16/2023] [Indexed: 01/20/2023]
Abstract
Following a pediatric stroke, outcome measures selected for monitoring functional recovery and development vary widely. We sought to develop a toolkit of outcome measures that are currently available to clinicians, possess strong psychometric properties, and are feasible for use within clinical settings. A multidisciplinary group of clinicians and scientists from the International Pediatric Stroke Organization comprehensively reviewed the quality of measures in multiple domains described in pediatric stroke populations including global performance, motor and cognitive function, language, quality of life, and behavior and adaptive functioning. The quality of each measure was evaluated using guidelines focused on responsiveness and sensitivity, reliability, validity, feasibility, and predictive utility. A total of 48 outcome measures were included and were rated by experts based on the available evidence within the literature supporting the strengths of their psychometric properties and practical use. Only three measures were found to be validated for use in pediatric stroke: the Pediatric Stroke Outcome Measure, the Pediatric Stroke Recurrence and Recovery Questionnaire, and the Pediatric Stroke Quality of Life Measure. However, multiple additional measures were deemed to have good psychometric properties and acceptable utility for assessing pediatric stroke outcomes. Strengths and weaknesses of commonly used measures including feasibility are highlighted to guide evidence-based and practicable outcome measure selection. Improving the coherence of outcome assessment will facilitate comparison of studies and enhance research and clinical care in children with stroke. Further work is urgently needed to close the gap and validate measures across all clinically significant domains in the pediatric stroke population.
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Affiliation(s)
- Samantha J Feldman
- Department of Psychology, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Lauren A Beslow
- Division of Neurology, Children's Hospital of Philadelphia, Departments of Neurology and Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Ryan J Felling
- Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Laura A Malone
- Johns Hopkins University School of Medicine and the Kennedy Krieger Institute, Baltimore, Maryland
| | - Michaela Waak
- Pediatric Critical Care Research Group, Child Health Research Centre, The University of Queensland, Queensland, Australia; Pediatric Intensive Care Unit, Queensland Children's Hospital, South Brisbane, Australia
| | - Stuart Fraser
- Division of Vascular Neurology, Department of Pediatrics, University of Texas Health Science Center, Houston, Texas
| | - Nihal Bakeer
- Indiana Hemophilia and Thrombosis Center, Indianapolis, Indiana
| | - Jo Ellen M Lee
- Department of Neurology, Nationwide Children's Hospital, Columbus, Ohio
| | | | - Melissa M Howard
- Casa Colina Hospital and Centers for Healthcare, Pomona, California
| | - Beth Anne Cavanaugh
- Division of Pediatric Neurology, Department of Pediatrics, University of Tennessee Health Science Center, Le Bonheur Children's Hospital, Memphis, Tennessee
| | - Robyn Westmacott
- Department of Psychology, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Lori C Jordan
- Division of Pediatric Neurology, Department of Pediatrics, Vanderbilt University Medical Center, Nashville, Tennessee.
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Maddux AB, VanBuren JM, Jensen AR, Holubkov R, Alvey JS, McQuillen P, Mourani PM, Meert KL, Burd RS. Post-discharge rehabilitation and functional recovery after pediatric injury. Injury 2022; 53:2795-2803. [PMID: 35680434 PMCID: PMC9808527 DOI: 10.1016/j.injury.2022.05.023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/21/2022] [Accepted: 05/15/2022] [Indexed: 02/02/2023]
Abstract
INTRODUCTION Variability in rehabilitation disposition has been proposed as a trauma center quality metric. Benchmarking rehabilitation disposition is limited by a lack of objective measures of functional impairment at discharge. The primary aim of this study was to determine the relative contribution of patient characteristics and hospitalization factors associated with inpatient and outpatient rehabilitation after discharge. The secondary aims were to evaluate the sensitivity of the Functional Status Scale (FSS) score for identifying functional impairments at hospital discharge and track post-discharge recovery. PATIENTS AND METHODS We report a planned secondary analysis of a prospective observational study of seriously injured children (<15 years old) enrolled at seven pediatric trauma centers. Functional Status Scale (FSS) score was measured for pre-injury, hospital discharge, and 6-month follow-up timepoints. Multinomial logistic regression identified factors associated with three dispositions: home without rehabilitation services, home with outpatient rehabilitation, and inpatient rehabilitation. Relative weight analysis was used to identify the impact of individual factors associated with inpatient or outpatient rehabilitation disposition. RESULTS We analyzed 427 children with serious injuries. Functional impairment at discharge was present in 103 (24.1%) children, including 43/337 (12.8%) discharged without services, 12/38 (31.6%) discharged with outpatient rehabilitation, and 44/47 (93.6%) discharged to inpatient rehabilitation. In multivariable modeling, variables most contributing to prediction of inpatient rehabilitation were severe initial Glasgow coma scale (GCS), injured body region, and functional impairment at discharge. Severe initial GCS, private insurance, and extremity injury were independently associated with disposition with outpatient rehabilitation. Patients discharged without services or with outpatient rehabilitation most frequently had motor impairments that improved during the next 6 months. Patients discharged to inpatient rehabilitation had impairments in all domains, with many improving within 6 months. A higher proportion of patients discharged to inpatient rehabilitation had residual impairments at follow-up. CONCLUSION Injury characteristics and discharge impairment were associated with discharge to inpatient rehabilitation. The FSS score identified impairments needing inpatient rehabilitation and characterized improvements after discharge. Less severe impairments needing outpatient rehabilitation were not identified by the FSS score.
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Affiliation(s)
- Aline B. Maddux
- Department of Pediatrics, Section of Critical Care Medicine, University of Colorado School of Medicine and Children’s Hospital Colorado, 13121 E 17th Ave, MS 8414, Aurora, CO, 80045, United States,Corresponding author at: Pediatric Critical Care, University of Colorado School of Medicine, Children’s Hospital Colorado, Education 2 South, 13121 East 17th Avenue, MS 8414, Aurora, CO 80045. (A.B. Maddux)
| | - John M. VanBuren
- Department of Pediatrics, University of Utah School of Medicine, 295 Chipeta Way, Salt Lake City, UT, 84108, United States
| | - Aaron R. Jensen
- Department of Surgery, University of California San Francisco and UCSF Benioff Children’s Hospital, 1411 East 31st St, Oakland, CA, 94602, United States
| | - Richard Holubkov
- Department of Pediatrics, University of Utah School of Medicine, 295 Chipeta Way, Salt Lake City, UT, 84108, United States
| | - Jessica S. Alvey
- Department of Pediatrics, University of Utah School of Medicine, 295 Chipeta Way, Salt Lake City, UT, 84108, United States
| | - Patrick McQuillen
- Department of Pediatrics, Benioff Children’s Hospital, University of California, San Francisco, 1550 Fourth St, San Francisco, CA, 94158, United States
| | - Peter M. Mourani
- Department of Pediatrics, Section of Critical Care Medicine, University of Colorado School of Medicine and Children’s Hospital Colorado, 13121 E 17th Ave, MS 8414, Aurora, CO, 80045, United States,Department of Pediatrics, Section of Critical Care, Arkansas Children’s, 13 Children’s Way, Slot 842, Little Rock, AR, 72202, United States
| | - Kathleen L Meert
- Department of Pediatrics, Children’s Hospital of Michigan, Central Michigan University, 3901 Beaubien, Detroit, MI, 48201, United States
| | - Randall S. Burd
- Division of Trauma and Burn Surgery, Children’s National Hospital, 111 Michigan Avenue NW, Washington, DC 20010, United States
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Han B, Yang JK, Ling AY, Ma M, Kipps AK, Shin AY, Beshish AG. Early Functional Status After Surgery for Congenital Heart Disease: A Single-Center Retrospective Study. Pediatr Crit Care Med 2022; 23:109-117. [PMID: 34593740 DOI: 10.1097/pcc.0000000000002838] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES The objective of this study is to investigate the change in functional status in infants, children, and adolescents undergoing congenital heart surgery using the Functional Status Scale. DESIGN A single-center retrospective study. SETTING A 26-bed cardiac ICU in a free-standing university-affiliated tertiary children's hospital. PATIENTS All patients 0-18 years who underwent congenital heart surgery from January 1, 2014, to December 31, 2017. INTERVENTIONS None. MEASUREMENTS AND MIN RESULTS The primary outcome variable was change in Functional Status Scale scores from admission to discharge. Additionally, two binary outcomes were derived from the primary outcome: new morbidity (change in Functional Status Scale ≥ 3) and unfavorable functional outcome (change in Functional Status Scale ≥ 5); their association with risk factors was assessed using modified Poisson regression. Out of 1,398 eligible surgical encounters, 65 (4.6%) and 15 (1.0%) had evidence of new morbidity and unfavorable functional outcomes, respectively. Higher Surgeons Society of Thoracic and the European Association for Cardio-Thoracic Surgery score, single-ventricle physiology, and longer cardiopulmonary bypass time were associated with new morbidity. Longer hospital length of stay was associated with both new morbidity and unfavorable outcome. CONCLUSIONS This study demonstrates the novel application of the Functional Status Scale on patients undergoing congenital heart surgery. New morbidity was noted in 4.6%, whereas unfavorable outcome in 1%. There was a small change in the total Functional Status Scale score that was largely attributed to changes in the feeding domain. Higher Society of Thoracic and the European Association for Cardio-Thoracic Surgery score, single-ventricle physiology, and longer cardiopulmonary bypass times were associated with new morbidity, whereas longer hospital length of stay was associated with both new morbidity and unfavorable outcome. Further studies with larger sample size will need to be done to confirm our findings and to better ascertain the utility of Functional Status Scale on this patient population.
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Affiliation(s)
- Brian Han
- Department of Pediatrics, Division of Cardiology, Lucile Packard Children's Hospital Stanford, Stanford University Medical Center, Palo Alto, CA
| | - Jeffrey K Yang
- Department of Pediatrics, Lucile Packard Children's Hospital Stanford, Stanford University Medical Center, Palo Alto, CA
| | - Albee Y Ling
- Department of Medicine, Quantitative Sciences Unit, Stanford University School of Medicine, Palo Alto, CA
| | - Michael Ma
- Department of Cardiothoracic Surgery, Lucile Packard Children's Hospital Stanford, Stanford University Medical Center, Palo Alto, CA
| | - Alaina K Kipps
- Department of Pediatrics, Division of Cardiology, Lucile Packard Children's Hospital Stanford, Stanford University Medical Center, Palo Alto, CA
| | - Andrew Y Shin
- Department of Pediatrics, Division of Cardiology, Lucile Packard Children's Hospital Stanford, Stanford University Medical Center, Palo Alto, CA
| | - Asaad G Beshish
- Department of Pediatrics, Division of Cardiology, Children's Healthcare of Atlanta, Emory University School of Medicine, Atlanta, GA
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Sundaram M, Hendy J. Functional assessment scales and their use in the pediatric intensive care unit. JOURNAL OF PEDIATRIC CRITICAL CARE 2022. [DOI: 10.4103/jpcc.jpcc_66_22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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The Association Between Functional Status and Health-Related Quality of Life Following Discharge from the Pediatric Intensive Care Unit. Neurocrit Care 2021; 35:347-357. [PMID: 34272680 PMCID: PMC9126134 DOI: 10.1007/s12028-021-01271-8] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2021] [Accepted: 05/04/2021] [Indexed: 02/05/2023]
Abstract
BACKGROUND Despite one third of children with acquired brain injury (ABI) experiencing new functional impairments following critical care admission, there is limited research investigating the impact of new functional impairments on overall health-related quality of life (HRQOL) or among important HRQOL domains. We aimed to investigate the association between new functional impairments, measured by the Functional Status Scale (FSS), and HRQOL in pediatric patients with ABI after critical care. METHODS We conducted a secondary analysis of a prospective observational study of 275 children aged 2 months to 18 years with ABI. The primary exposure evaluated was change in FSS from baseline at hospital discharge, categorized per prior work (no change, 1-2 point increase, and ≥ 3 point increase). The primary outcome was overall HRQOL 6 months after hospital discharge, measured by the Pediatric Quality of Life Inventory (PedsQL) total score. Secondary outcomes were PedsQL domain scores. PedsQL total and domain scores were transformed into age-standardized z scores for analyses. Multiple linear regression models evaluated the association between FSS change category and HRQOL (overall and domain z scores) when controlling for demographic and clinical characteristics and were reported as β-coefficients with 95% confidence intervals. RESULTS Complete data were analyzed for 195 (71%) children, including 127 with traumatic brain injury. New functional impairment was common with 32 (16%) patients experiencing FSS increases ≥ 3, 50 (26%) patients with FSS increases of 1-2 points, and 113 (58%) patients with no change from prehospital baseline. The majority of children (63%) demonstrated HRQOL ratings ≥ 1 standard deviation below healthy age-based standards (z scores ≤ - 1). Regression models demonstrated older age, female sex, presence of comorbidities, and preadmission cardiopulmonary resuscitation were all significantly associated with poorer overall HRQOL (all p < 0.05). FSS increase ≥ 3 at discharge was significantly associated with worse overall HRQOL at follow-up (β = - 1.07; 95% confidence interval = - 1.63 to - 0.52) when controlling for the aforementioned significant factors, and significantly improved model fit (p value for change = 0.001). Similar findings in secondary analyses were found for physical domain scores, with FSS increase showing a significant association with worse physical HRQOL scores and improvements in model fit. Change in FSS was not significantly associated with other HRQOL domain scores (emotional, social, school, psychosocial). CONCLUSIONS Many children with ABI after critical care experience new functional impairments (FSS increases) and worse HRQOL than healthy peers. FSS increase at discharge is a significant risk factor for worse HRQOL in the months after hospital discharge and improves HRQOL models beyond illness and demographic variables alone.
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Oprandi MC, Oldrati V, delle Fave M, Panzeri D, Gandola L, Massimino M, Bardoni A, Poggi G. Processing Speed and Time since Diagnosis Predict Adaptive Functioning Measured with WeeFIM in Pediatric Brain Tumor Survivors. Cancers (Basel) 2021; 13:cancers13194776. [PMID: 34638261 PMCID: PMC8508451 DOI: 10.3390/cancers13194776] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2021] [Revised: 09/20/2021] [Accepted: 09/22/2021] [Indexed: 12/31/2022] Open
Abstract
Simple Summary Brain tumor (BT) survivors show difficulties in adaptive functioning (AF) and in acquiring independence (e.g., graduating, finding employment, building strong relationships, and being independent). The aim of our observational retrospective study is to explore the contribution of different clinical and cognitive variables in explaining and predicting the AF outcomes of BT survivors, measured with the Functional Independence Measure for Children (WeeFIM). The analysis demonstrated that processing speed and time since diagnosis are the main explanatory variables. Other clinical factors, such as age at diagnosis and hydrocephalus, differentially influence functional skills according to distinct domains (i.e., self-care, mobility, and cognition). The identification of the clinical factors influencing AF could suggest targets on which to focus attention. By successfully assessing, understanding, and managing AF, it will be possible to improve its management in pediatric BT survivors. Abstract (1) Background: Brain tumor (BT) survivors show difficulties in the acquisition of developmental milestones, related to academic achievement, vocational employment, social relationships, and autonomy. The skills underlying adaptive functioning (AF) are usually damaged in BT survivors due to the presence of the brain tumor, treatment-related factors, and other neurological sequelae. In this study, we aimed to explore the contribution of different cognitive factors in children with BT to AF, considering diagnosis-related variables. (2) Methods: Standardized cognitive assessment was undertaken and clinical information was collected from a retrospective cohort of 78 children with a BT, aged between 6 and 18 year old at the time of the assessment. Regression models were computed to investigate the influence of the selected variables on daily functional skills as measured by the Functional Independence Measure for Children (WeeFIM). (3) Results: The analyses showed that the main explanatory variables are processing speed and time since diagnosis. Other clinical variables, such as age at diagnosis and hydrocephalus, differentially influence functional skills according to distinct domains (i.e., self-care, mobility, and cognition). (4) Conclusions: The main explanatory variables of AF that emerged in our models point to a potential target of improving AF management in pediatric BT survivors.
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Affiliation(s)
- Maria Chiara Oprandi
- Neuro-Oncological and Neuropsychological Rehabilitation Unit, Scientific Institute, IRCCS E. Medea, Bosisio Parini, 23842 Lecco, Italy; (V.O.); (M.d.F.); (D.P.); (A.B.); (G.P.)
- Correspondence:
| | - Viola Oldrati
- Neuro-Oncological and Neuropsychological Rehabilitation Unit, Scientific Institute, IRCCS E. Medea, Bosisio Parini, 23842 Lecco, Italy; (V.O.); (M.d.F.); (D.P.); (A.B.); (G.P.)
| | - Morena delle Fave
- Neuro-Oncological and Neuropsychological Rehabilitation Unit, Scientific Institute, IRCCS E. Medea, Bosisio Parini, 23842 Lecco, Italy; (V.O.); (M.d.F.); (D.P.); (A.B.); (G.P.)
| | - Daniele Panzeri
- Neuro-Oncological and Neuropsychological Rehabilitation Unit, Scientific Institute, IRCCS E. Medea, Bosisio Parini, 23842 Lecco, Italy; (V.O.); (M.d.F.); (D.P.); (A.B.); (G.P.)
| | - Lorenza Gandola
- Department of Medical Oncology and Hematology, Pediatrics Unit, Fondazione IRCCS Istituto Nazionale dei Tumori, 20133 Milan, Italy; (L.G.); (M.M.)
| | - Maura Massimino
- Department of Medical Oncology and Hematology, Pediatrics Unit, Fondazione IRCCS Istituto Nazionale dei Tumori, 20133 Milan, Italy; (L.G.); (M.M.)
| | - Alessandra Bardoni
- Neuro-Oncological and Neuropsychological Rehabilitation Unit, Scientific Institute, IRCCS E. Medea, Bosisio Parini, 23842 Lecco, Italy; (V.O.); (M.d.F.); (D.P.); (A.B.); (G.P.)
| | - Geraldina Poggi
- Neuro-Oncological and Neuropsychological Rehabilitation Unit, Scientific Institute, IRCCS E. Medea, Bosisio Parini, 23842 Lecco, Italy; (V.O.); (M.d.F.); (D.P.); (A.B.); (G.P.)
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Molteni E, Ranzini MBM, Beretta E, Modat M, Strazzer S. Individualized Prognostic Prediction of the Long-Term Functional Trajectory in Pediatric Acquired Brain Injury. J Pers Med 2021; 11:675. [PMID: 34357142 PMCID: PMC8305391 DOI: 10.3390/jpm11070675] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2021] [Revised: 07/09/2021] [Accepted: 07/15/2021] [Indexed: 11/30/2022] Open
Abstract
In pediatric acquired brain injury, heterogeneity of functional response to specific rehabilitation treatments is a key confound to medical decisions and outcome prediction. We aimed to identify patient subgroups sharing comparable trajectories, and to implement a method for the early prediction of the long-term recovery course from clinical condition at first discharge. 600 consecutive patients with acquired brain injury (7.4 years ± 5.2; 367 males; median GCS = 6) entered a standardized rehabilitation program. Functional Independent Measure scores were measured yearly, until year 7. We classified the functional trajectories in clusters, through a latent class model. We performed single-subject prediction of trajectory membership in cases unseen during model fitting. Four trajectory types were identified (post.prob. > 0.95): high-start fast (N = 92), low-start fast (N = 168), slow (N = 130) and non-responders (N = 210). Fast responders were older (chigh = 1.8; clow = 1.1) than non-responders and suffered shorter coma (chigh = -14.7; clow = -4.3). High-start fast-responders had shorter length of stay (c = -1.6), and slow responders had lower incidence of epilepsy (c = -1.4), than non-responders (p < 0.001). Single-subject trajectory could be predicted with high accuracy at first discharge (accuracy = 0.80). In conclusion, we stratified patients based on the evolution of their response to a specific treatment program. Data at first discharge predicted the response over 7 years. This method enables early detection of the slow responders, who show poor post-acute functional gains, but achieve recovery comparable to fast responders by year 7. Further external validation in other rehabilitation programs is warranted.
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Affiliation(s)
- Erika Molteni
- School of Biomedical Engineering & Imaging Sciences, King’s College London, London SE1 7EU, UK; (E.M.); (M.B.M.R.); (M.M.)
| | - Marta Bianca Maria Ranzini
- School of Biomedical Engineering & Imaging Sciences, King’s College London, London SE1 7EU, UK; (E.M.); (M.B.M.R.); (M.M.)
| | - Elena Beretta
- Acquired Brain Injury Unit, Scientific Institute IRCCS E. Medea, 22040 Bosisio Parini, Italy;
| | - Marc Modat
- School of Biomedical Engineering & Imaging Sciences, King’s College London, London SE1 7EU, UK; (E.M.); (M.B.M.R.); (M.M.)
| | - Sandra Strazzer
- Acquired Brain Injury Unit, Scientific Institute IRCCS E. Medea, 22040 Bosisio Parini, Italy;
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Abstract
Supplemental Digital Content is available in the text. Objectives: To conduct a scoping review to 1) describe findings and determinants of physical functioning in children during and/or after PICU stay, 2) identify which domains of physical functioning are measured, 3) and synthesize the clinical and research knowledge gaps. Data Sources: A systematic search was conducted in PubMed, Embase, Cumulative Index to Nursing and Allied Health Literature, and Cochrane Library databases following the Preferred Reporting Items for Systematic Reviews and Meta-analyses extension for Scoping Reviews guidelines. Study Selection: Two investigators independently screened and included studies against predetermined criteria. Data Extraction: One investigator extracted data with review by a second investigator. A narrative analyses approach was used. Data Synthesis: A total of 2,610 articles were identified, leaving 68 studies for inclusion. Post-PICU/hospital discharge scores show that PICU survivors report difficulties in physical functioning during and years after PICU stay. Although sustained improvements in the long-term have been reported, most of the reported levels were lower compared with the reference and baseline values. Decreased physical functioning was associated with longer hospital stay and presence of comorbidities. A diversity of instruments was used in which mobility and self-care were mostly addressed. CONCLUSIONS: The results show that children perceive moderate to severe difficulties in physical functioning during and years after PICU stay. Longitudinal assessments during and after PICU stay should be incorporated, especially for children with a higher risk for poor functional outcomes. There is need for consensus on the most suitable methods to assess physical functioning in children admitted to the PICU.
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Nacoti M, Fazzi F, Biroli F, Zangari R, Barbui T, Kochanek PM. Addressing Key Clinical Care and Clinical Research Needs in Severe Pediatric Traumatic Brain Injury: Perspectives From a Focused International Conference. Front Pediatr 2021; 8:594425. [PMID: 33537259 PMCID: PMC7849211 DOI: 10.3389/fped.2020.594425] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/13/2020] [Accepted: 11/06/2020] [Indexed: 12/28/2022] Open
Abstract
Traumatic brain injury (TBI) is a leading cause of morbidity and mortality in children and adolescents. Survivors of severe TBI are more prone to functional deficits, resulting in poorer school performance, poor health-related quality of life (HRQoL), and increased risk of mental health problems. Critical gaps in knowledge of pathophysiological differences between children and adults concerning TBI outcomes, the paucity of pediatric trials and prognostic models and the uncertain extrapolation of adult data to pediatrics pose significant challenges and demand global efforts. Here, we explore the clinical and research unmet needs focusing on severe pediatric TBI to identify best practices in pathways of care and optimize both inpatient and outpatient management of children following TBI.
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Affiliation(s)
- Mirco Nacoti
- Pediatric Intensive Care Unit, Department of Anesthesia and Intensive Care, Papa Giovanni XXIII Hospital, Bergamo, Italy
| | - Francesco Fazzi
- Pediatric Intensive Care Unit, Department of Anesthesia and Intensive Care, Papa Giovanni XXIII Hospital, Bergamo, Italy
| | - Francesco Biroli
- Fondazione per la Ricerca dell'Ospedale di Bergamo Research Foundation, Papa Giovanni XXIII Hospital, Bergamo, Italy
| | - Rosalia Zangari
- Fondazione per la Ricerca dell'Ospedale di Bergamo Research Foundation, Papa Giovanni XXIII Hospital, Bergamo, Italy
| | - Tiziano Barbui
- Fondazione per la Ricerca dell'Ospedale di Bergamo Research Foundation, Papa Giovanni XXIII Hospital, Bergamo, Italy
| | - Patrick M. Kochanek
- Department of Critical Care Medicine, Safar Center for Resuscitation Research, John G Rangos Research Center, University of Pittsburgh Medical Center Children's Hospital of Pittsburgh, University of Pittsburgh School of Medicine, Pittsburgh, PA, United States
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Steinhart S, Raz-Silbiger S, Beeri M, Gilboa Y. Occupation Based Telerehabilitation Intervention for Adolescents with Myelomeningocele: A Pilot Study. Phys Occup Ther Pediatr 2021; 41:176-191. [PMID: 32856511 DOI: 10.1080/01942638.2020.1807448] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
AIMS This pilot study examined the impact of an occupation based intervention using a telerehabilitation format with adolescents with myelomeningocele (MMC). METHODS We conducted a nonrandomized pilot study including four adolescents ages 14-18 with MMC. The intervention program included 10-12 sessions of the Cognitive Orientation to daily Occupational Performance remotely delivered via videoconferencing. Outcome measures included the Canadian Occupational Performance Measure (COPM), Wee-Functional Independence Measure;(Wee-FIM), and the Pediatric Quality of Life Inventory (PedsQL). Assessments were administered at baseline, post intervention and at three-month follow-up. RESULTS Following intervention, participants rated their performance as having improved 2 points on the COPM for 8 out of 12 trained goals and on 2 out of 8 untrained goals. At 3-month follow-up improvement was reported on 9 out of 12 trained goals and 3 out of 8 untrained goals All participants made clinically significant improvements on the Wee-FIM total score following intervention and improvements were maintained at 3-month follow-up. The intervention effect on the PedsQL was inconclusive. Feedback interviews suggested that participants experience high satisfaction from the results and implementation of the intervention. CONCLUSIONS Our results demonstrate potential efficacy of occupation based teleintervention for adolescents with MMC.
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Affiliation(s)
- Shoshana Steinhart
- ALYN Hospital - Pediatric and Adolescent Rehabilitation Center, Jerusalem, Israel
| | - Shani Raz-Silbiger
- ALYN Hospital - Pediatric and Adolescent Rehabilitation Center, Jerusalem, Israel
| | - Maurit Beeri
- ALYN Hospital - Pediatric and Adolescent Rehabilitation Center, Jerusalem, Israel
| | - Yafit Gilboa
- School of Occupational Therapy, Faculty of Medicine, The Hebrew University of Jerusalem, Jerusalem, Israel
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Abstract
OBJECTIVES To evaluate the functional outcomes in critically ill children with severe sepsis using the Pediatric Overall Performance Category scale and Pediatric Cerebral Performance Category scale and to evaluate the risk factors for "worse outcomes." DESIGN Prospective observational cohort study. SETTING Tertiary care PICU from September 2017 to October 2019. PATIENTS One hundred twenty-one children with severe sepsis, 2 months to 17 years old, admitted to PICU. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Pediatric Overall Performance Category and Pediatric Cerebral Performance Category scores were recorded at admission, PICU discharge, at 3 months and 1 year after discharge. "New disability" was defined as Pediatric Overall Performance Category and Pediatric Cerebral Performance Category score change "from baseline score" by greater than or equal to 1 category. Risk factors for "worse outcomes" (defined as "death" or "new disability") were evaluated by univariate and multivariate analysis. At admission, 33% (n = 39) had mild to moderate "overall disability" (Pediatric Overall Performance Category) and 26% (n = 32) had mild to moderate "cognitive disability" (Pediatric Cerebral Performance Category). At PICU discharge (n = 89 children), 50.5% (n = 45) had "new disability" in overall function (Pediatric Overall Performance Category scores) and 28% (n = 25) had "new disability" in cognitive function (Pediatric Cerebral Performance Category scores). At 3 months follow-up (n = 85 children), "new disability" at PICU discharge improved in 65% (n = 28/43) and 50% (n = 12/24) of those with "overall disability" (Pediatric Overall Performance Category) and "cognitive disability" (Pediatric Cerebral Performance Category), respectively. At 1-year follow-up (n = 84 children), only 5% (n = 2/43) had residual "new disability" in overall function (Pediatric Overall Performance Category) and 14% (n = 3/21) had residual "new disability" in cognitive function. PICU mortality was 26% (n = 32). The proportion with "worse outcomes" was 64% (n = 77). Risk factors for worse outcomes on univariate analysis included higher Pediatric Index of Mortality-3 scores, day 1 pediatric Sequential Organ Failure Assessment score, receiving cardiopulmonary resuscitation during the ICU stay, and treatments received such as ventilation and Vasoactive-Inotrope Score. On multivariate analysis, only day 1 pediatric Sequential Organ Failure Assessment score and receiving cardiopulmonary resuscitation during the ICU stay were found to be statistically significant. CONCLUSIONS Children with severe sepsis had significant "new onset" mild to moderate functional disability at PICU discharge, and most of these children recovered within 1 year after PICU discharge. Day 1 pediatric Sequential Organ Failure Assessment score and patient receiving cardiopulmonary resuscitation during the ICU stay were found to be the significant risk factors of "worse outcomes."
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Nasr IW, Chun Y, Kannan S. Neuroimmune responses in the developing brain following traumatic brain injury. Exp Neurol 2019; 320:112957. [PMID: 31108085 DOI: 10.1016/j.expneurol.2019.112957] [Citation(s) in RCA: 36] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2018] [Revised: 05/10/2019] [Accepted: 05/15/2019] [Indexed: 12/26/2022]
Abstract
Traumatic brain injury (TBI) is one of the leading causes of both acute and long-term morbidity in the pediatric population, leading to a substantial, long-term socioeconomic burden. Despite the increase in the amount of pre-clinical and clinical research, treatment options for TBI rely heavily on supportive care with very limited targeted interventions that improve the acute and chronic sequelae of TBI. Other than injury prevention, not much can be done to limit the primary injury, which consists of tissue damage and cellular destruction. Secondary injury is the result of the ongoing complex inflammatory pathways that further exacerbate tissue damage, resulting in the devastating chronic outcomes of TBI. On the other hand, some level of inflammation is essential for neuronal regeneration and tissue repair. In this review article we discuss the various stages of the neuroimmune response in the immature, pediatric brain in the context of normal maturation and development of the immune system. The developing brain has unique features that distinguish it from the adult brain, and the immune system plays an integral role in CNS development. Those features could potentially make the developing brain more susceptible to worse outcomes, both acutely and in the long-term. The neuroinflammatory reaction which is triggered by TBI can be described as a highly intricate interaction between the cells of the innate and the adaptive immune systems. The innate immune system is triggered by non-specific danger signals that are released from damaged cells and tissues, which in turn leads to neutrophil infiltration, activation of microglia and astrocytes, complement release, as well as histamine release by mast cells. The adaptive immune response is subsequently activated leading to the more chronic effects of neuroinflammation. We will also discuss current attempts at modulating the TBI-induced neuroinflammatory response. A better understanding of the role of the immune system in normal brain development and how immune function changes with age is crucial for designing therapies to appropriately target the immune responses following TBI in order to enhance repair and plasticity.
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Affiliation(s)
- Isam W Nasr
- Pediatric Surgery, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD 21287, United States of America
| | - Young Chun
- Pediatric Surgery, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD 21287, United States of America
| | - Sujatha Kannan
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD 21287, United States of America.
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Outcome Measures for Pediatric Traumatic Brain Injury: Comparing Established and Novel Tests. Pediatr Crit Care Med 2018; 19:1086-1087. [PMID: 30395111 DOI: 10.1097/pcc.0000000000001731] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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