Objective: To quantify moral distress in neonatal ICU and PICU clinicians and to identify associated factors. Design: A national cross-sectional survey of clinicians working in an neonatal ICU or PICU. Moral distress was assessed with the Moral Distress Scale-Revised and by self-rating. Depersonalization was assessed on the subscale of the Maslach Burnout Inventory. Respondents reported their attendance at each of six hospital supports that may serve to mitigate moral distress in frontline staff. Analyses compared outcomes across respondent characteristics and hierarchical linear regression evaluated individual, ICU, hospital, and regional effects. Setting: Eligible ICUs were PICUs and level-3 neonatal ICUs in Canada. Subjects: Eligible participants had worked in the participating ICU for more than 3 months. Interventions: None. Measurements and Main Results: We identified 54 eligible ICUs from 31 hospitals. Forty-nine Canadian neonatal ICUs and PICUs (91%) contributed 2,852 complete responses for a 45.2% response rate. Most respondents were nurses (64.9%) or from a neonatal ICU (66.5%). The median and interquartile range Moral Distress Scale-Revised were 79 (52–113); 997 respondents (34.2%) had Moral Distress Scale-Revised scores greater than or equal to 100, and 234 respondents (8.3%) strongly agreed that work caused them significant moral distress. Nurses had a median (interquartile range) Moral Distress Scale-Revised score of 85 (57–121), 19 points higher than physicians and 8 points higher than respiratory therapists (p < 0.0001). Moral Distress Scale-Revised scores increased from 53 (35–79) for those working in ICU less than 1 year to 83 (54–120) in those working in ICU more than 30 years (p < 0.0001); 22.5% reported high degrees of depersonalization, which was associated with moral distress (p < 0.0001). Variability in Moral Distress Scale-Revised scores was explained by individual-level (92%), hospital-level (5%), and ICU-level effects (1%). Frequency of participation in potentially mitigating hospital supports had small effects (< 10 points) on mean Moral Distress Scale-Revised scores. Conclusions: Moral distress is common in clinicians working in ICUs for children. Addressing moral distress will require interventions tailored to individuals in higher-risk groups.

BACKGROUND: Computerized physician order entry and clinical decision support systems are electronic prescribing strategies that are increasingly used to improve patient safety. Previous reviews show limited effect on patient outcomes. Our objective was to assess the impact of electronic prescribing strategies on medication errors and patient harm in hospitalized patients. METHODS: MEDLINE, EMBASE, CENTRAL, and CINAHL were searched from January 2007 to January 2018. We included prospective studies that compared hospital-based electronic prescribing strategies with control, and reported on medication error or patient harm. Data were abstracted by two reviewers and pooled using random effects model. Study quality was assessed using the Effective Practice and Organisation of Care and evidence quality was assessed using Grading of Recommendations Assessment, Development, and Evaluation. RESULTS: Thirty-eight studies were included; comprised of 11 randomized control trials and 27 non-randomized interventional studies. Electronic prescribing strategies reduced medication errors (RR 0.24 (95% CI 0.13, 0.46), I 2 98%, n=11) and dosing errors (RR 0.17 (95% CI 0.08, 0.38), I 2 96%, n=9), with both risk ratios significantly affected by advancing year of publication. There was a significant effect of electronic prescribing strategies on adverse drug events (ADEs) (RR 0.52 (95% CI 0.40, 0.68), I 2 0%, n=2), but not on preventable ADEs (RR 0.55 (95% CI 0.30, 1.01), I 2 78%, n=3), hypoglycemia (RR 1.03 (95% CI 0.62-1.70), I 2 28%, n=7), length of stay (MD −0.18 (95% −1.42, 1.05), I 2 94%, n=7), or mortality (RR 0.97 (95% CI 0.79, 1.19), I 2 74%, n=9). The quality of evidence was rated very low. DISCUSSION: Electronic prescribing strategies decrease medication errors and adverse drug events, but had no effect on other patient outcomes. Conservative interpretations of these findings are supported by significant heterogeneity and the preponderance of low-quality studies.

Abstract-C-reactive protein (CRP), a characteristic inflammatory marker, is a powerful predictor of cardiovascular events.Recent data suggest that CRP may also promote atherogenesis through inducing endothelial dysfunction. Lectin-like oxidized low-density lipoprotein (oxLDL) receptor-1 (LOX-1) is a newly identified endothelial receptor for oxLDL that plays a pivotal role in oxLDL-induced endothelial dysfunction. Whether CRP may regulate endothelial LOX-1 and induce endothelial dysfunction through this receptor is unknown. In the present study, we studied the in vitro effect of CRP on LOX-1 expression in human aortic endothelial cells (HAECs) and the role of LOX-1 in CRP-induced human monocyte adhesion to endothelium and oxLDL uptake by endothelial cells. Incubation of HAECs with CRP enhanced, in a dose-and time-dependent manner, LOX-1 mRNA and protein levels. Induction of LOX-1 protein was already present at 5 g/mL CRP and reached a maximum at 25 g/mL. This effect was reduced by antibodies against CD32/CD64, endothelin-1 (ET-1) and interleukin-6 (IL-6). The extent of stimulation of LOX-1 achieved by CRP was comparable to that elicited by high glucose and IL-6 and remained unchanged in presence of these factors. Finally, CRP increased, through LOX-1, both human monocyte adhesion to endothelial cells and oxLDL uptake by these cells. We conclude that CRP enhances endothelial LOX-1 expression and propose a new mechanism by which CRP may promote endothelial dysfunction, that of inducing LOX-1. Key Words: C-reactive protein Ⅲ endothelium Ⅲ lectin-like oxidized low-density lipoprotein receptor-1 Ⅲ inflammation A therosclerosis is an inflammatory process that takes place in the arterial wall and is accompanied by a systemic response. Since the concept of an inflammatory soil of atherosclerosis has been validated, 1-3 serum markers of inflammation have been identified as risk markers for cardiovascular disease. Among these, highly sensitive C-reactive protein (CRP) has been proven to be the strongest predictor of cardiovascular events. 4 -5 Besides being a risk marker, CRP may further play a pivotal role in promoting atherogenesis. Arguing for this hypothesis, it has been shown that CRP increases the release of inflammatory cytokines, 6 enhances the binding of monocytes to endothelium, 7 and favors macrophage foam cell formation. 8 CRP also decreases endothelial nitric oxide synthase activation while increasing the expression of endothelial cell adhesion molecules, chemokines, endothelin-1 (ET-1), and plasminogen activator inhibitor-1. 9 -13 Unregulated uptake of oxidized low-density lipoprotein (oxLDL) by vascular cells is a crucial step in atherogenesis. Endothelial lectin-like oxidized LDL receptor-1 (LOX-1) is the major receptor of oxLDL, 14 and accumulating evidences indicate that oxLDL uptake through this receptor induces endothelial dysfunction. oxLDL binding to endothelial LOX-1 generates superoxide anions, decreases nitric oxide production, and activates nuclear factor-B (NF-B). [15][16] Furthermore, inhibit...

Objective: Our objective was to construct a prospective high-quality and high-frequency database combining patient therapeutics and clinical variables in real time, automatically fed by the information system and network architecture available through fully electronic charting in our PICU. The purpose of this article is to describe the data acquisition process from bedside to the research electronic database. Design: Descriptive report and analysis of a prospective database. Setting: A 24-bed PICU, medical ICU, surgical ICU, and cardiac ICU in a tertiary care free-standing maternal child health center in Canada. Patients: All patients less than 18 years old were included at admission to the PICU. Interventions: None. Measurements and Main Results: Between May 21, 2015, and December 31, 2016, 1,386 consecutive PICU stays from 1,194 patients were recorded in the database. Data were prospectively collected from admission to discharge, every 5 seconds from monitors and every 30 seconds from mechanical ventilators and infusion pumps. These data were linked to the patient’s electronic medical record. The database total volume was 241 GB. The patients’ median age was 2.0 years (interquartile range, 0.0–9.0). Data were available for all mechanically ventilated patients (n = 511; recorded duration, 77,678 hr), and respiratory failure was the most frequent reason for admission (n = 360). The complete pharmacologic profile was synched to database for all PICU stays. Following this implementation, a validation phase is in process and several research projects are ongoing using this high-fidelity database. Conclusions: Using the existing bedside information system and network architecture of our PICU, we implemented an ongoing high-fidelity prospectively collected electronic database, preventing the continuous loss of scientific information. This offers the opportunity to develop research on clinical decision support systems and computational models of cardiorespiratory physiology for example.

Hospitalization in a PICU is a life-altering experience for children and their families. Yet, little is known about the well-being of these children after their discharge. We are describing the outcome of PICU survivors at a PICU clinic 2 months after discharge. DESIGN: Prospective cohort study.SETTING: PICU and PICU clinic of CHU Sainte-Justine. PATIENTS:Prospective cohort study of children admitted for greater than or equal to 4 days, greater than or equal to 2 days of invasive ventilation, odds ratio greater than or equal to 4 days of noninvasive ventilation at Centre Hospitalier Universitaire Sainte-Justine. PATIENTS:Prospective cohort study of children admitted for greater than or equal to 4 days, greater than or equal to 2 days of invasive ventilation, or greater than or equal to 4 days of noninvasive ventilation at Centre Hospitalier Universitaire Sainte-Justine PICU. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS:Patients were evaluated by a pediatric intensivist 2 months after discharge at the follow-up clinic. They were asked to fill out validated questionnaires. One hundred thirty-two patients were followed from October 2018 to September 2020. The PICU diagnoses were respiratory illness (40.9%), head trauma, and septic shock (7.6%). Average length of PICU stay was 28.5 ± 84.2 days (median 7 d). Sixty-one percent were intubated. Symptoms reported by families were as follows: fatigue (9.9%), sleep disturbances (20.5%), feeding difficulties (12.1%), and voice change and/or stridor (9.8%). Twenty-one percent of school-aged children reported school delays. Twenty-seven children demonstrated communication delays, 45% gross motor function delays, 41% fine motor delays, 37% delays in problem-solving, and 49% delays in personalsocial functioning. Quality of Life scores were 78.1 ± 20.5 and 80.0 ± 17.5 for physical and psychosocial aspects, respectively. Fourteen percent of parents reported financial difficulties, 42% reported symptoms of anxiety, 29% symptoms of depression.CONCLUSIONS: PICU survivors and their families experience significant physical and psychosocial morbidities after their critical illness. PICU follow-up is crucial to determine the outcome of these children and develop interventions.

A nine-month-old female infant presented with a two-day history of vomiting, diarrhea and decreased urine output, along with a three-month history of lethargy and reduced tone. Her early development had been normal, but regression of skills had begun three months before presentation, with a loss of gross motor skills progressing to a loss of head control. The child had been exclusively breastfed until solids were slowly introduced over the last month. Her family was of South-East Asian ethnic origin, and her mother was a strict life-long vegan who took prenatal vitamins during pregnancy.On examination, the baby was sleepy and pale. Her weight was 6.65 kg (< 3rd percentile), height was 69 cm (25th percentile) and head circumference was 41 cm (< 3rd percentile). The liver edge was 3 cm below the costal margin. The splenic tip was palpable. Her axial and peripheral muscle tone was decreased, with frog-like posture of both legs. No antigravity power was exhibited. Reflexes were 3+ in her lower extremities and 2+ in her upper extremities. She was able to fix visually but did not follow.Laboratory investigations showed a hemo- /L. The blood smear showed pancytopenia with severe leukoerythroblastic change, dysplastic red blood cells and rare hypersegmented neutrophils; it appeared severely megaloblastic overall (Figure 1). The albumin level was 18 (range 34-42) g/L. Vitamin B 12 level was less than 37 (range 133-695) pmol/L (lower reporting limit), and the folate level was 14 (range 7-36) nmol/L. A bone marrow biopsy showed morphological changes consistent with megaloblastic anemia. Magnetic resonance imaging (MRI) of the patient's brain showed generalized atrophy. Metabolic and biochemical investigations, including acylcarnitine profile, plasma amino acid and urine organic acids, showed abnormalities consistent with dietary protein deficiency.Because the infant had been mostly breastfed with limited solid intake, we examined the mother. Her complete blood count was normal, but her vitamin B 12 level was low at 63 (adult reference range 133-695, deficient < 107) pmol/L. Review of the mother's prenatal blood work indicated a normal hemoglobin level, with a normal mean corpuscular volume.The infant's anemia was managed initially with a slow transfusion of packed red blood cells. Intramuscular injections of vitamin B 12 (1000 µg) were given daily for seven days, then weekly for the next month, along with oral iron supplementation. Nasogastric feeding with formula was initiated because of poor suck, and breastfeeding was maintained for comfort. The mother was started on oral B 12 supplementation.Five months later, the infant was consuming solid baby food and infant formula, and her growth parameters had improved. Her muscle tone and neurologic status had also improved. The complete blood count and B 12 levels were normal. • Infant B 12 sufficiency is related to maternal levels via neonatal stores at birth and the amount in breast milk. Cases Vitamin• Vitamin B 12 deficiency in infants, although rare, is important to recogn...

In pediatric TBI with intracranial hypertension, mannitol and 3 % hypertonic saline are commonly used, but dose and therapeutic threshold for use vary without clear indications for one versus another. Controlled trials are warranted, but several barriers were identified, including high exclusion rate, multiple co-interventions, and care variability.

Our study confirms that many children with severe TBI do not undergo ICP monitoring, mainly due to rapid improvement or moribund status. A subgroup of patients, with reassuring cerebral CT scan, was not monitored. Further research is necessary to assess if imaging should be considered in ICP indication, as in adult guidelines.