Asma A. Taha

Effect of early nutritional support on intensive care unit length of stay and neurological status at discharge in children with severe traumatic brain injury.

ABSTRACT Pediatric severe traumatic brain injury treatment guidelines for nutrition indicate that “there are insufficient data to support a treatment guideline for this topic” (P. D. Adelson et al., 2003). Based on adult studies, the guideline provided an option for practitioners to start nutritional support within 72 hours of admission and full replacement by day 7. This retrospective, descriptive correlation study examined the timing of nutritional supplement initiation and the timing of achieving full caloric intake in relation to length of stay (LOS) in the intensive care unit (ICU) and patient disposition status at discharge from hospital in children 8–18 years old. Median time to initiation of nutrition was 1.5 days (0.02–11.9 days), and full caloric goals were achieved in 3.4 days (0.5–19.6 days). Median ICU LOS was 2.1 days (0.01–97.9 days). Overall, 48% of patients were discharged home; 28% experienced mild, moderate, or severe disability; and 24% either died or survived in a vegetative state. Early initiation and achieving full caloric intake were both positively correlated with shorter LOS in the ICU (p < .01, Spearman’s rho correlational matrix) and better disposition status at discharge from the hospital (p < .05, Kruskal–Wallis test).

Substance Abuse in Middle Eastern Adolescents Living in Two Different Countries: Spiritual, Cultural, Family and Personal Factors

It is estimated that the percentage of students using illicit substances by sixth grade has tripled over the last decade not only in developed countries but in developing countries as well probably due to the transition to a more Western society. Although much has been done to understand the mechanisms underlying substance abuse, few studies have been conducted with minority ethnic and religious groups such as Middle Eastern Youth. The primary goal of this study was to determine whether there are differences in factors contributing to substance abuse in adolescents from Lebanon versus the USA and to decipher the role of spirituality, religion, and culture among other factors that may influence substance abuse. A correlational cross-sectional design was used with adolescents living in two different countries: Los Angeles, California and Beirut, Lebanon. Muslim adolescents had significantly less rates of alcohol and substance use than Christians in both Lebanon and Los Angeles. More years lived in the USA increases the likelihood of abuse for both Muslims and Christians. Attachment to God and family was negatively associated with substance abuse. These results among others facilitate a better understanding of the influence of culture, religion, family and personal factors on substance abuse. Culturally sensitive interventions could benefit from the findings of this pilot study.

Cervical spine imaging for young children with inflicted trauma: Expanding the injury pattern

AIM The purpose of this study was to document the incidence and pattern of cervical spine (c-spine) injuries in children below 36months with inflicted trauma. METHODS An IRB approved, prospective cohort study was performed between July 2011 and January 2016. Inclusion criteria were: age below 36months, loss of consciousness after inflicted trauma, and one initial head computed tomography finding: a subdural, intraventricular, intraparenchymal, subarachnoid hemorrhage, diffuse axonal injury, hypoxic injury, or cerebral edema. A protocol of brain and neck magnetic resonance imaging and angiography was obtained within 48h. Variables were compared by t-test and Fisher-exact test. RESULTS There were 53 children (median age: five months; range: 1-35months), 38 males (71.7%), of which seven died (13.2%). C-spine injury was identified in 8 (15.1%): ligamentous injury (2), vertebral artery shear injury (1), atlantooccipital dissociation (AOD) (1), cord injury with cord epidural hematoma (2), and isolated cord epidural hematoma (2). Retinal hemorrhages (p=0.02), shaking (p=0.04), lower Glasgow coma score (GCS) (p=0.01), brain infarcts (p=0.01), and hypoxic/ischemic injury (p=0.01) were associated with c-spine injury. One with AOD died. Six had significant disability. CONCLUSION For small children with inflicted trauma, the c-spine injury incidence is 15.1%. The injury pattern includes retinal hemorrhages, shaking, lower GCS, and brain injury. Evaluation of shaken infants should include c-spine imaging. LEVEL OF EVIDENCE Level 2 A- This is a prospective cohort study with complete follow-up to hospital discharge or death. In all cases, inflicted trauma was confirmed. Owing to the nature of child abuse, the precise time of injury is not known. All children underwent a strict imaging protocol on arrival to hospital that was supervised on a prospective basis.

Neonatal Intracerebral Hemorrhage: Mechanisms, Managements, and the Outcomes

Intracerebral hemorrhage is a multifactorial disorder with heterogeneous etiologies and potentially long-term debilitating outcomes. We review all available evidence regarding the current strategies for management of intracerebral hemorrhage. It is clear that prompt detection and treatment does affect the outcome; nevertheless, prevention of intracerebral hemorrhage remains the best strategy.

Evaluating a Mental Health Program for Palestinian Refugees in Lebanon

Medecins sans Frontière, an international non-governmental organization, initiated a mental health program for Palestinian refugees living in Lebanon. To evaluate the impact of the program after its completion, focus groups were conducted with three target groups: (1) patients, (2) staff, and (3) local community stakeholders. Participants voiced overall satisfaction with the program. The program provided easy access, good quality care, decreased stigma, as perceived by participants, and revealed a sense of community contentedness. In addition, several short-term outcomes were achieved, such as increasing the numbers of patients visiting the center/ receiving mental health treatment. However, lack of planning for sustainability and proper procedures for hand-over of the program constituted a major downfall. Program discontinuation posed ethical dilemmas, common in provisional interventions in underprivileged refugee communities.

Delirium in the Critically Ill Child

Purpose/Objective: The purposes of this article are to describe the scientific literature on assessment, prevention, and management of delirium in critically ill children and to articulate the implications for clinical nurse specialists, in translating the evidence into practice. Description: A literature search was conducted in 4 databases—OvidMEDLINE, Cumulative Index to Nursing and Allied Health Literature, PsychINFO, and Web of Science—using the terms “delirium,” “child,” and “critically ill” for the period of 2006 to 2016. Outcome: The scientific literature included articles on diagnosis, prevalence, risk factors, adverse outcomes, screening tools, prevention, and management. The prevalence of delirium in critically ill children is up to 30%. Risk factors include age, developmental delay, severity of illness, and mechanical ventilation. Adverse outcomes include increased mortality, hospital length of stay, and cost for the critically ill child with delirium. Valid and reliable delirium screening tools are available for critically ill children. Prevention and management strategies include interventions to address environmental triggers, sleep disruption, integrated family care, and mobilization. Conclusion: Delirium is a common occurrence for the critically ill child. The clinical nurse specialist is accountable for leading the implementation of practice changes that are based on evidence to improve patient outcomes. Screening and early intervention for delirium are key to mitigating adverse outcomes for critically ill children.

Ce: Preventing Contrast-induced Acute Kidney Injury

&NA;Diagnostic radiographic imaging scans using intravascular iodinated contrast media can lead to various complications. The most salient of these is contrast-induced acute kidney injury (CI-AKI) or contrast-induced nephropathy, a potentially costly and serious patient safety concern. Prevention strategies are the cornerstone of evidence-based clinical management for patients receiving contrast agents. These include preprocedure screening, stratification of patients based on risk factors, and protective interventions, the most important of which is hydration both before and after the radiographic imaging scan. There is a gap, however, between best evidence and clinical practice in terms of exact hydration protocols. Nurses play an important role in nephropathy prevention and need to be familiar with CI-AKI as a potential complication of radiographic imaging scans. In order to ensure safe, high-quality care, nurses must be involved in efforts to prevent CI-AKI as well as interventions that minimize patients’ risk of kidney injury.

Utilization of national patient registries by clinical nurse specialist: opportunities and implications.

Purpose: The purpose of this article was to describe how clinical nurse specialists can be instrumental in getting involved in the process of joining a national disease registry to improve patient outcomes. Background: Clinical patient data registries provide longitudinal data on developmental outcomes in chronic, lifelong diseases affecting children. Recognition and application of their use have historically allowed for collection of benchmarking data, improved understanding of disease processes and patient outcomes, and improved quality of life. Description of the Project: A group of advanced practice nurses in a university-based multispecialty clinic, through evidence-based practice, embarked on the process of joining the National Spina Bifida Patient Registry sponsored by the Centers for Disease Control and Prevention. Outcome: By taking the lead as project managers, this group of advanced practice nurses obtained buy-in from physicians and multispecialty team members of the Spina Bifida Clinic in the university children’s hospital where they practice. An institutional review board application was submitted to their university children’s hospital internal review board and currently approved. Conclusion: This project demonstrates how dynamic utilization of core competencies through application of specific knowledge and skill sets supports the advanced practice nurse’s instrumental role in actively initiating, promoting, and supporting participation in clinical patient data registries that seek improved patient outcomes at the national level. Implications: Clinical nurse specialists quantify their role and purpose when connecting their interventions and influence to patient outcomes with utilization of resources, such as a national patient data registry.

The institutional review board: purpose and process.

The institutional review board (IRB) and the approval process may seem like overwhelming obstacles to many potential researchers. However, the purpose of the IRB and the process are quite simple and are explained here. Specifically, the committee types, members, and purpose are described. In addition, the 4 categories of review with examples and future changes anticipated are detailed. The goal of the article is to provide the clinical nurse specialist (CNS) with sufficient knowledge and/or review to quell the anxiety limiting the research potential of the CNS. There are 2 types of IRB (Figure 1). The biomedical IRB primarily reviews research involving biologics, investigational drugs, devices, and experimental clinical procedures. The health services IRB primarily reviews behavioral, epidemiologic, and health services research. The IRB is a committee composed of at least 5 members who have sufficient experience, expertise, and diversity to make an informed decision on whether the research is ethical, informed consent is sufficient, and appropriate safeguards have been provided. Furthermore, the committee membership must include men and women from different professions and at least 1 community member. The community member must be a person who is not affiliated with the institution or in the immediate family of a person affiliated with the institution. Anyone who conducts research, reviews research applications, or teaches a course with a student research requirement must complete the Protecting Human Research Participants certificate provided by the National Institutes of Health. For the CNS feeling the need for review of research ethics, online modules are available from the National Cancer Institute and include reviews of clinical trials, translational research, and other research training such as the National Health and Nutrition Examination Surveys Web tutorial (http://www.cdc.gov/nchs/tutorials/ Nhanes) and access to the caBIG Training Portal (https:// cabig.nci.nih.gov/training/?pid=primary.2006-07-07.491164 1845&sid=secondary.2006-10-24.0611379107&status=True). The online certification is available at the National Institutes of Health Office of Extramural Research (http:// phrp.nihtraining.com). Once completed, the certification is valid for 2 years. Evidence of the Protecting Human Research Participants certification must be attached to all IRB applications. The committee is formally charged with reviewing and approving, in advance, and monitoring, and rereviewing by periodic review biomedical and behavioral research involving human and animal subjects. The purpose of the committee is to protect the rights and welfare of the research subjects. Committee members consider internationally recognized ethical principles discussed in the Belmont Report (1979) and applied to human subjects: (1) respect for persons as autonomous agents with the capacity for self-determination; (2) persons with diminished autonomy are entitled to protection; (3) beneficence meaning to do no harm and to protect from harm; and (4) justice that requires the research benefits and burdens be distributed equitably. The committee determines that the risks to subjects are balanced by the potential benefits to society, and that the subject selection process represents an equitable distribution of risks and benefits to eligible subjects.