Nonpharmacological Interventions to Reduce Sedation and General Anesthesia in Pediatric MRI: A Meta-analysis.

CONTEXT: Nonpharmacological strategies are increasingly used in pediatric procedures, but in pediatric MRI, sedation and general anesthesia are still commonly required. OBJECTIVES: To evaluate the effectiveness of nonpharmacological interventions in reducing use of sedation and general anesthesia in pediatric patients undergoing MRI, and to investigate effects on scan time, image quality, and anxiety. DATA SOURCES: We searched Ovid Medline, CINAHL, Embase, and CENTRAL from inception through October 10, 2022. STUDY SELECTION: We included randomized controlled trials and quasi-experimental designs comparing the effect of a nonpharmacological intervention with standard care on use of sedation or general anesthesia, scan time, image quality, or child and parental anxiety among infants (<2 years), children, and adolescents (2-18 years) undergoing MRI. DATA EXTRACTION: Standardized instruments were used to extract data and assess study quality. RESULTS: Forty-six studies were eligible for the systematic review. Limited to studies on children and adolescents, the meta-analysis included 20 studies with 33 873 patients. Intervention versus comparator analysis showed that nonpharmacological interventions were associated with reduced need for sedation and general anesthesia in the randomized control trials (risk ratio, 0.68; 95% confidence interval, 0.48-0.95; l2 = 35%) and nonrandomized studies (risk ratio, 0.58; 95% confidence interval, 0.51-0.66; l2 = 91%). The effect was largest among children aged 3 to 10 years when compared with older children and adolescents aged 11 to 18 years. LIMITATIONS: There was substantial heterogeneity among nonrandomized studies. CONCLUSIONS: Nonpharmacological interventions must be considered as standard procedure in infants, children, and adolescents undergoing MRI.

Nutrition and preparation of blenderized tube feeding in children and adolescents with neurological impairment: A scoping review.

BACKGROUND: The use of homemade tube feeding formula has become increasingly popular for children requiring enteral nutrition. This project aimed to investigate nutrition and preparation of blenderized tube feeding in the field of children and adolescents with neurological impairment. METHODS: A scoping review was performed using established methodologies. In January 2021, we searched PubMed, Embase, CINAHL Complete, the Cochrane Central Register of Controlled Trials, and gray literature to identify relevant articles. MAJOR FINDINGS: Twenty-two papers were included describing the composition of food items, preparation procedures, and food safety. No randomized controlled trials and only a few prospective studies were included. A broad variety of food items from all food groups and many examples of recipes were presented. Most recipes provided 1.0 kcal/ml but tended to contain less energy and nutrients than expected, which could be due to preparation issues, such as sieving and the high viscosity of the blend. Preparation requires a commercial-grade household blender and diligence to ensure thorough household hygiene for adequate food safety. CONCLUSIONS: This review revealed practical experience in the nutrition and preparation aspects of blenderized tube feeding but minimal empirical evidence. Multiple examples of the composition of food items and preparation procedures for blenderized tube feeding were found, but uncertainty regarding the ideal composition or preparation was also exposed. The future of blenderized tube feeding would benefit from clinically tested recipes that include an evaluation of nutrients, viscosity, and microbial contamination, as well as the effect of the food's appearance and scent on the target group.

Nutritional screening of children and adolescents with cerebral palsy: a scoping review.

AIM: To examine nutritional screening methods for children and adolescents with cerebral palsy. METHOD: A scoping review was performed using established methodologies. In June 2020 we searched PubMed, Embase, CINAHL Complete, and the Cochrane Central Register of Controlled Trials to identify articles on tools/methods for nutritional screening of our target groups. RESULTS: Thirty studies were included, containing various tools/methods used to identify under- and/or overnutrition by weight/height, circumferences, skinfolds, questionnaires, and/or technically advanced or invasive methods. Questionnaires, weight/height, circumferences, and skinfolds were considered feasible based on clinical utility, whereas bioelectrical impedance analysis and blood samples were not. INTERPRETATION: We identified two screening tools for undernutrition that include no physical measurements, but did not find any screening tools for overweight and obesity. Most of the studies recommended one or more methods, indicating that determining nutritional status most likely includes a combination of methods, not all of which may be feasible in clinical practice. What this paper adds No nutritional screening tool using anthropometry or body composition was discovered. Heterogenous methods to identify under- and/or overnutrition are recommended. Preferable methods for nutritional screening include assessment of body composition. A validated nutritional screening tool for identification of overweight is warranted.

Nonpharmacological interventions to reduce sedation/general anaesthesia in paediatric patients undergoing magnetic resonance imaging: A systematic review and meta-analysis protocol.

BACKGROUND: Magnetic resonance imaging is frequently used in paediatrics and requires the child/adolescent to remain still for 45 min or more. The long and narrow scanner gantry makes loud noises and may cause anxiety. To complete the procedure, children and adolescents are often sedated or receive general anaesthesia. Our primary aim is to determine whether nonpharmacological interventions designed to mentally prepare, support or distract children, and adolescents are effective in reducing the need for sedation and general anaesthesia. METHODS: We will conduct a systematic review with meta-analysis by searching the following electronic databases: Ovid MEDLINE, CINAHL, Embase and CENTRAL, as well as databases for ongoing trials. Eligibility criteria are based on the participants, intervention, comparator and outcome (PICO) framework. We will include intervention studies with comparator group(s) with no restriction on date. Two reviewers will independently screen titles/abstracts, and three reviewers will assess the full texts of potentially relevant studies. Data will be extracted, and the methodological quality will be assessed using Cochrane risk of bias tools. If the data allow, we will perform a meta-analysis using a random effects model on the primary outcome, sedation/general anaesthesia. A narrative synthesis will supplement the statistical analysis. Quality of evidence for the primary outcome will be assessed using the grading of recommendations, assessment, development and evaluations (GRADE) approach. DISCUSSION: Our findings will provide directions for future research and may guide clinicians in terms of which type(s) of intervention(s) to implement to reduce the use of sedation/general anaesthesia during paediatric magnetic resonance imaging.

Sleep in hospitalized children and adolescents: A scoping review.

Hospitalized children and adolescents are at risk of short sleep and subsequent adverse health effects, but little is known about actual sleep duration, the factors that cause sleep disturbances in an inpatient pediatric setting, and what has been done to promote sleep in this population. The aim of this review was to systematically identify, categorize, and synthesize the literature on sleep in children and adolescents in an inpatient setting. We searched five electronic databases (PubMed, CENTRAL, CINAHL, PsycINFO, and Scopus) and of the 3770 references identified, 28 were eligible for inclusion. From studies reporting age-specific sleep durations, we found that four out of nineteen fell within the National Sleep Foundations recommendations for age-specific sleep durations. Reported causes of sleep disturbances were primarily related to modifiable, external factors, e.g., nursing care activities and noise from equipment and other patients. Sleep-promoting interventions seemed acceptable to patients, parents, and healthcare professionals. However, the literature in this area is heterogeneous regarding methodology, reporting, and population characteristics. Our findings underline the importance of prioritizing and optimizing sleep in hospitalized pediatric patients and highlight the need for standardization in the planning and reporting of studies within this field.

Unannounced vs announced in situ simulation of emergency teams: Feasibility and staff perception of stress and learning.

BACKGROUND: Simulation-based medical education, often used for teaching teamwork, can be conducted in different settings: off-site (simulation centers or other settings away from clinical units) or in situ (real clinical environment), where the latter can be either announced or unannounced. Simulation in general, but especially unannounced in situ simulation, has been described as stressful and stress can affect learning. The aim of this study was to evaluate feasibility and the perception of learning and stress. METHODS: Sixteen standardized in situ simulations were planned in an emergency department on eight predetermined dates, with one unannounced and one announced simulation per day. Authentic ad hoc teams were formed based on the on-call staff and included doctors, nurses, radiographers, biochemist, porters, and secretaries. Data were collected using questionnaires and the State-Trait Anxiety Inventory. RESULTS: Eleven of the 16 in situ simulations were completed. Self-perceived learning was "good" or "very good" for 27/47 (57%) participants and 33/50 (66%) in unannounced vs announced in situ simulation (P = 0.33). Two of 47 (4%) in unannounced in situ simulation "agreed or partly agreed" that in situ simulation was stressful or unpleasant vs 12/50 (24%) in announced in situ simulation (P = 0.06). CONCLUSION: No significant difference was found between unannounced and announced in situ simulation among emergency department staff according to self-perceived learning and self-perceived stress. This is relevant for the future planning of simulation when considering what is to be achieved from implementing different designs for simulation-based medical education.

Cardiotocography interpretation skills and the association with size of maternity unit, years of obstetric work experience and healthcare professional background: a national cross-sectional study.

INTRODUCTION: We aimed to examine whether cardiotocography (CTG) knowledge, interpretation skills and decision-making measured by a written assessment were associated with size of maternity unit, years of obstetric work experience and healthcare professional background. MATERIAL AND METHODS: A national cross-sectional study in the setting of a CTG teaching intervention involving all 24 maternity units in Denmark. Participants were midwives (n = 1260) and specialists (n = 269) and residents (n = 142) in obstetrics and gynecology who attended a 1-day CTG course and answered a 30-item multiple-choice question test. Associations between mean test score and work conditions were analyzed using multivariable robust regression, in which the three variables were mutually adjusted. RESULTS: Participants from units with > 3000 deliveries/year scored higher on the test than participants from units with < 1000 deliveries/year (3000-3999 deliveries/year: mean difference 0.8, p < 0.0001; > 4000 deliveries/year: mean difference 0.5, p = 0.006). Participants with < 15 years of work experience scored higher than participants with > 15 years of experience (15-20 years of experience: mean difference - 0.6, p = 0.007; > 20 years experience: mean difference - 0.9, p < 0.0001). No differences were detected concerning professional background. CONCLUSIONS: CTG knowledge, interpretation skills and decision-making measured by a written assessment were positively associated with working in large maternity units and having < 15 years of obstetric work experience. This might indicate a challenge in maintaining CTG skills in small units and among experienced staff but could also reflect different levels of motivation, test familiarity and learning culture. Whether the findings are transferable to the clinical setting was not examined.

Curriculum development for a national cardiotocography education program: a Delphi survey to obtain consensus on learning objectives.

OBJECTIVE: To define learning objectives for a national cardiotocography (CTG) education program based on expert consensus. DESIGN: A three-round Delphi survey. POPULATION AND SETTING: One midwife and one obstetrician from each maternity unit in Denmark were appointed based on CTG teaching experience and clinical obstetric experience. METHODS: Following national and international guidelines, the research group determined six topics as important when using CTG: fetal physiology, equipment, indication, interpretation, clinical management, and communication/responsibility. In the first Delphi round, participants listed one to five learning objectives within the predefined topics. Responses were analyzed by a directed approach to content analysis. Phrasing was modified in accordance with Bloom's taxonomy. In the second and third Delphi rounds, participants rated each objective on a five-point relevance scale. Consensus was predefined as objectives with a mean rating value of ≥ 3. MAIN OUTCOME MEASURES: A prioritized list of CTG learning objectives. RESULTS: A total of 42 midwives and obstetricians from 21 maternity units were invited to participate, of whom 26 completed all three Delphi rounds, representing 18 maternity units. The final prioritized list included 40 objectives. The highest ranked objectives emphasized CTG interpretation and clinical management. The lowest ranked objectives emphasized fetal physiology. Mean ratings of relevance ranged from 3.15 to 5.00. CONCLUSIONS: National consensus on CTG learning objectives was achieved using the Delphi methodology. This was an initial step in developing a valid CTG education program. A prioritized list of objectives will clarify which topics to emphasize in a CTG education program.

The effect of dyad versus individual simulation-based ultrasound training on skills transfer.

CONTEXT: Dyad practice may be as effective as individual practice during clinical skills training, improve students' confidence, and reduce costs of training. However, there is little evidence that dyad training is non-inferior to single-student practice in terms of skills transfer. OBJECTIVES: This study was conducted to compare the effectiveness of simulation-based ultrasound training in pairs (dyad practice) with that of training alone (single-student practice) on skills transfer. METHODS: In a non-inferiority trial, 30 ultrasound novices were randomised to dyad (n = 16) or single-student (n = 14) practice. All participants completed a 2-hour training programme on a transvaginal ultrasound simulator. Participants in the dyad group practised together and took turns as the active practitioner, whereas participants in the single group practised alone. Performance improvements were evaluated through pre-, post- and transfer tests. The transfer test involved the assessment of a transvaginal ultrasound scan by one of two clinicians using the Objective Structured Assessment of Ultrasound Skills (OSAUS). RESULTS: Thirty participants completed the simulation-based training and 24 of these completed the transfer test. Dyad training was found to be non-inferior to single-student training: transfer test OSAUS scores were significantly higher than the pre-specified non-inferiority margin (delta score 7.8%, 95% confidence interval -3.8-19.6%; p = 0.04). More dyad (71.4%) than single (30.0%) trainees achieved OSAUS scores above a pre-established pass/fail level in the transfer test (p = 0.05). There were significant differences in performance scores before and after training in both groups (pre- versus post-test, p < 0.01) with large effect sizes (Cohen's d = 3.85) and no significant interactions between training type and performance (p = 0.59). The dyad group demonstrated higher training efficiency in terms of simulator score per number of attempts compared with the single-student group (p = 0.03). CONCLUSION: Dyad practice improves the efficiency of simulation-based training and is non-inferior to individual practice in terms of skills transfer.

A structured four-step curriculum in basic laparoscopy: development and validation.

OBJECTIVE: The objective of this study was to develop a four-step curriculum in basic laparoscopy consisting of validated modules integrating a cognitive component, a practical component and a procedural component. DESIGN: A four-step curriculum was developed. The methodology was different for each step. Step 1: A 1-day course in basic laparoscopy developed on the background of a regional needs analysis. Step 2: A multiple-choice test, developed and validated through interviews with experts in laparoscopy and subsequently through a Delphi audit involving regional chief physicians. Step 3: A procedural training task (a salpingectomy) on a validated virtual reality simulator. Step 4: An operation on a patient (a salpingectomy) with following formative assessment based on a validated assessment scale. SETTING: University hospital, Copenhagen, Denmark. POPULATION: Fifty-two first-year residents in obstetrics and gynecology from 2009 to 2011. METHOD: Observational cohort study. MAIN OUTCOME MEASURE: Completion rate. RESULTS: All participants completed step 1 and improved post-course test scores compared with pre-course test scores, p = 0.001. Step 2 was completed by 75% (37/52); all improved test scores after 6 months, p = 0.001. Step 3 was completed by 75%. Participants used 238 min (range 75-599) and 38 repetitions (range 8-99) to reach proficiency level on a virtual reality simulator. Step 4 was completed by 55%. There was no correlation between test scores and simulator training time. Protected training time was correlated with increasing completion rate. CONCLUSION: A four-step curriculum in basic laparoscopy is applicable in residency training. Protected training time correlated with increasing completion rate.

International multispecialty consensus on how to evaluate ultrasound competence: a Delphi consensus survey.

OBJECTIVES: To achieve international consensus across multiple specialties on a generic ultrasound rating scale using a Delphi technique. METHODS: Ultrasound experts from Obstetrics-Gynaecology, Surgery, Urology, Radiology, Rheumatology, Emergency Medicine, and Gastro-Enterology representing North America, Australia, and Europe were identified. A multi-round survey was conducted to obtain consensus between these experts. Of 60 invited experts, 44 experts agreed to participate in the first Delphi round, 41 remained in the second round, and 37 completed the third Delphi round. Seven key elements of the ultrasound examination were identified from existing literature and recommendations from international ultrasound societies. All experts rated the importance of these seven elements on a five-point Likert scale in the first round and suggested potential new elements for the assessment of ultrasound skills. In the second round, the experts re-rated all elements and a third round was conducted to allow final comments. Agreement on which elements to include in the final rating scale was pre-defined as more than 80% of the experts rating an element four or five, on importance to the ultrasound examination. RESULTS: Two additional elements were suggested by more than 10% of the experts in the first Delphi round. Consensus was obtained to include these two new elements along with five of the original elements in the final assessment instrument: 1) Indication for the examination 2) Applied knowledge of ultrasound equipment 3) Image optimization 4) Systematic examination 5) Interpretation of images 6) Documentation of examination and 7) Medical decision making. CONCLUSION: International multispecialty consensus was achieved on the content of a generic ultrasound rating scale. This is the first step to ensure valid assessment of clinicians in different medical specialties using ultrasound.

Vacuum extraction: development and test of a procedure-specific rating scale.

OBJECTIVES: To develop and validate an Objective Structured Assessment of Technical Skills (OSATS) scale for vacuum extraction. DESIGN: Two-part study design: Primarily, development of a procedure-specific checklist for vacuum extraction. Hereafter, validation of the developed OSATS scale for vacuum extraction in a prospective observational study. SETTING: Rigshospitalet, University Hospital of Copenhagen. POPULATION: For development, an obstetric expert from each labor ward in Denmark (28 departments) was invited to participate. For validation, nine first-year residents and 10 chief physicians with daily work in the obstetric field were tested. METHODS: The Delphi method was used for development of the scale. In a simulated vacuum extraction scenario, first-year residents and obstetric chief physicians were rated using the developed OSATS scale for vacuum extraction to test construct validity of the scale. MAIN OUTCOME MEASURES: Consensus for the content of the scale. To test the scale of Cronbach's alpha, interclass correlation and differential item function was calculated in the prospective study. RESULTS: 89% completed the first and 61% completed the second Delphi round. Hereafter, consensus was obtained. There was a significant difference between residents' and experts' performance for total score and for the score of the separate parts of the scale. Cronbach's alpha for total score and for the separate parts of the scale was 0.91-0.95 and interclass correlation 0.84-0.9. CONCLUSIONS: The OSATS scale for vacuum extraction is a reliable test for differentiating between competence levels in a simulated setting.