Skeletal Muscle Ultrasonography in Nutrition and Functional Outcome Assessment of Critically Ill Children: Experience and Insights From Pediatric Disease and Adult Critical Care Studies

Evidence suggests that critically ill children develop muscle wasting, which could affect outcomes. Muscle ultrasound has been used to track muscle wasting and association with outcomes in critically ill adults but not children. This review aims to summarize methodological considerations of muscle ultrasound, structural findings, and possibilities for its application in the assessment of nutrition and functional outcomes in critically ill children. Medline, Embase, and CINAHL databases were searched up until April 2016. Articles describing skeletal muscle ultrasound in children and critically ill adults were analyzed qualitatively for details on techniques and findings. Thickness and cross‐sectional area of various upper and lower body muscles have been studied to quantify muscle mass and detect muscle changes. The quadriceps femoris muscle is one of the most commonly measured muscles due to its relation to mobility and is sensitive to changes over time. However, the margin of error for quadriceps thickness is too wide to reliably detect muscle changes in critically ill children. Muscle size and its correlation with strength and function also have not yet been studied in critically ill children. Echogenicity, used to detect compromised muscle structure in neuromuscular disease, may be another property worth studying in critically ill children. Muscle ultrasound may be useful in detecting muscle wasting in critically ill children but has not been shown to be sufficiently reliable in this population. Further study of the reliability and correlation with functional outcomes and nutrition intake is required before muscle ultrasound is routinely employed in critically ill children.     

The relative contribution of patient,provider and organizational influences to the appropriate diagnosis and management of diabetes mellitus

Objective To estimate the relative contribution of patient attributes, provider characteristics and organizational features of the doctors' workplace to the diagnosis and management of diabetes. Research design and methods In a factorial experimental design doctors (n = 192) viewed clinically authentic vignettes of ‘patients’ presenting with identical signs and symptoms. Doctor subjects were primary care doctors stratified according to gender and level of experience. During an in‐person interview scheduled between real patients, doctors were asked how they would diagnosis and manage the vignette ‘patients’ in clinical practice. Results This study considered the relative contribution of patient, doctor and organizational factors. Taken together patient attributes explained only 4.4% of the variability in diabetes diagnosis. Doctor factors explained only 2.0%. The vast majority of the explained variance in diabetes diagnosis was due to organizational factors (14.3%). Relative contributions combined (patient, provider, organizational factors) explained only 20% of the total variance. Conclusion Attempts to reduce health care variations usually focus on the education/activation of patients, or increased training of doctors. Our findings suggest that shifting quality improvement efforts to the area which contributes most to the creation and amplification of variations (organizational influences) may produce better results in terms of reduced variations in health care associated with diabetes.