bluuebunny/crossref_metadata_2025 huggingface dataset:
On the Use of Blood Samples for Measuring DNA Methylation in Ecological Epigenetic Studies
Authors: Husby Arild
Published: August 2020

Synopsis

There is increasing interest in understanding the potential for epigenetic factors to contribute to phenotypic diversity in evolutionary biology. One well studied epigenetic mechanism is DNA methylation, the addition of a methyl group to cytosines, which have the potential to alter gene expression depending on the genomic region in which it takes place. Obtaining information about DNA methylation at genome-wide scale has become straightforward with the use of bisulfite treatment in combination with reduced representation or whole-genome sequencing. While it is well recognized that methylation is tissue specific, a frequent limitation for many studies is that sampling-specific tissues may require sacrificing individuals, something which is generally undesirable and sometimes impossible. Instead, information about DNA methylation patterns in the blood is frequently used as a proxy tissue. This can obviously be problematic if methylation patterns in the blood do not reflect that in the relevant tissue. Understanding how, or if, DNA methylation in blood reflect DNA methylation patterns in other tissues is therefore of utmost importance if we are to make inferences about how observed differences in methylation or temporal changes in methylation can contribute to phenotypic variation. The aim of this review is to examine what we know about the potential for using blood samples in ecological epigenetic studies. I briefly outline some methods by which we can measure DNA methylation before I examine studies that have compared DNA methylation patterns across different tissues and, finally, examine how useful blood samples may be for ecological studies of DNA methylation. Ecological epigenetic studies are in their infancy, but it is paramount for the field to move forward to have detailed information about tissue and time dependence relationships in methylation to gain insights into if blood DNA methylation patterns can be a reliable bioindicator for changes in methylation that generate phenotypic variation in ecologically important traits.
Dimension of the Moduli Space of a Germ of Curve in ℂ2
Authors: Genzmer Yohann
Published: August 2020

In this article, we prove a formula that computes the generic dimension of the moduli space of a germ of irreducible curve in the complex plane. It is obtained from the study of the Saito module associated to the curve, which is the module of germs of holomorphic $1$-forms leaving the curve invariant.
Physical Activity for Oncological Patients in COVID-19 Era: No Time to Relax
Authors: Avancini Alice , Trestini Ilaria , Tregnago Daniela , Wiskemann Joachim , Lanza Massimo , Milella Michele , Pilotto Sara
Published: August 2020

Whereas the coronavirus disease 2019 (COVID-19) storm is relentlessly progressing worldwide, a great effort from scientific societies has been made to give recommendations for safely continuing oncological care, prioritizing the interventions according to patients' condition and type and stage of tumor. Nevertheless, to date no specific suggestions regarding physical activity and exercise in cancer patients during the COVID-19 era have been released, neglecting the potential deleterious effects of quarantine and sedentary behaviour (imposed as containment measures against COVID-19), particularly in these subjects. Moreover, literature is constantly consolidating the crucial impact of regular physical activity in cancer in reducing recurrence and mortality risk. In this commentary, we discuss possible adaptations of the recently published exercise guidelines to the current pandemic emergency, proposing various modalities to prevent or mitigate the physical inactivity risk in cancer patients.
Cost-Effectiveness of a National Sugar-Sweetened Beverage Tax to Reduce Cancer Burdens and Disparities in the United States
Authors: Du Mengxi , Griecci Christina F , Kim David D , Cudhea Frederick , Ruan Mengyuan , Eom Heesun , Wong John B , Wilde Parke E , Michaud Dominique S , Lee Yujin , Micha Renata , Mozaffarian Dariush , Zhang Fang Fang
Published: August 2020

Background

Sugar-sweetened beverage (SSB) consumption contributes to obesity, a risk factor for 13 cancers. Although SSB taxes can reduce intake, the health and economic impact on reducing cancer burdens in the United States are unknown, especially among low-income Americans with higher SSB intake and obesity-related cancer burdens.

Methods

We used the Diet and Cancer Outcome Model, a probabilistic cohort state-transition model, to project health gains and economic benefits of a penny-per-ounce national SSB tax on reducing obesity-associated cancers among US adults aged 20 years and older by income.

Results

A national SSB tax was estimated to prevent 22 075 (95% uncertainty interval [UI] = 16 040-28 577) new cancer cases and 13 524 (95% UI = 9841-17 681) cancer deaths among US adults over a lifetime. The policy was estimated to cost $1.70 (95% UI = $1.50-$1.95) billion for government implementation and $1.70 (95% UI = $1.48-$1.96) billion for industry compliance, while saving $2.28 (95% UI = $1.67-$2.98) billion cancer-related healthcare costs. The SSB tax was highly cost-effective from both a government affordability perspective (incremental cost-effectiveness ratio [ICER] = $1486, 95% UI = -$3516-$9265 per quality-adjusted life year [QALY]) and a societal perspective (ICER = $13 220, 95% UI = $3453-$28 120 per QALY). Approximately 4800 more cancer cases and 3100 more cancer deaths would be prevented, and $0.34 billion more healthcare cost savings would be generated among low-income (federal poverty-to-income ratio [FPIR] ≤ 1.85) than higher-income individuals (FPIR > 1.85).

Conclusions

A penny-per-ounce national SSB tax is cost-effective for cancer prevention in the United States, with the largest health gains and economic benefits among low-income Americans.
IGF-Binding Proteins, Adiponectin, and Survival in Metastatic Colorectal Cancer: Results From CALGB (Alliance)/SWOG 80405
Authors: Guercio Brendan J , Zhang Sui , Ou Fang-Shu , Venook Alan P , Niedzwiecki Donna , Lenz Heinz-Josef , Innocenti Federico , Pollak Michael N , Nixon Andrew B , Mullen Brian C , O’Neil Bert H , Shaw James E , Polite Blase N , Benson Al Bowen , Atkins James N , Goldberg Richard M , Brown Justin C , O’Reilly Eileen M , Mayer Robert J , Blanke Charles D , Fuchs Charles S , Meyerhardt Jeffrey A
Published: August 2020

Background

Energy balance-related biomarkers are associated with risk and prognosis of various malignancies. Their relationship to survival in metastatic colorectal cancer (mCRC) requires further study.

Methods

Baseline plasma insulin-like growth factor (IGF)-1, IGF-binding protein (IGFBP)-3, IGFBP-7, C-peptide, and adiponectin were measured at time of trial registration in a prospective cohort of patients with mCRC participating in a National Cancer Institute–sponsored trial of first-line systemic therapy. We used Cox proportional hazards regression to adjust for confounders and examine associations of each biomarker with overall survival (OS) and progression-free survival (PFS). P values are 2-sided.

Results

Median follow-up for 1086 patients was 6.2 years. Compared with patients in the lowest IGFBP-3 quintile, patients in the highest IGFBP-3 quintile experienced an adjusted hazard ratio (HR) for OS of 0.57 (95% confidence interval [CI] = 0.42 to 0.78; Pnonlinearity < .001) and for PFS of 0.61 (95% CI = 0.45 to 0.82; Ptrend = .003). Compared with patients in the lowest IGFBP-7 quintile, patients in the highest IGFBP-7 quintile experienced an adjusted hazard ratio for OS of 1.60 (95% CI = 1.30 to 1.97; Ptrend < .001) and for PFS of 1.38 (95% CI = 1.13 to 1.69; Ptrend < .001). Plasma C-peptide and IGF-1 were not associated with patient outcomes. Adiponectin was not associated with OS; there was a nonlinear U-shaped association between adiponectin and PFS (Pnonlinearity = .03).

Conclusions

Among patients with mCRC, high plasma IGFBP-3 and low IGFBP-7 were associated with longer OS and PFS. Extreme levels of adiponectin were associated with shorter PFS. These findings suggest potential avenues for prognostic and therapeutic innovation.
Cardiovascular Toxicity of Targeted Therapies for Cancer: An Overview of Systematic Reviews
Authors: Van Leeuwen Marina T , Luu Steven , Gurney Howard , Brown Martin R , Pearson Sallie-Anne , Webber Kate , Hunt Lee , Hong Soojung , Delaney Geoffrey P , Vajdic Claire M
Published: August 2020

Background

Several targeted therapies for cancer have been associated with cardiovascular toxicity. The evidence for this association has not been synthesized systematically nor has the quality of evidence been considered. We synthesized systematic review evidence of cardiovascular toxicity of individual targeted agents.

Methods

We searched MEDLINE, Embase, and the Cochrane Database of Systematic Reviews for systematic reviews with meta-analyses of cardiovascular outcomes for individual agents published to May 2020. We selected reviews according to prespecified eligibility criteria (International Prospective Register of Systematic Reviews CRD42017080014). We classified evidence of cardiovascular toxicity as sufficient, probable, possible, or indeterminate for specific cardiovascular outcomes based on statistical significance, study quality, and size.

Results

From 113 systematic reviews, we found at least probable systematic review evidence of cardiovascular toxicity for 18 agents, including high- and all-grade hypertension for bevacizumab, ramucirumab, axitinib, cediranib, pazopanib, sorafenib, sunitinib, vandetanib, aflibercept, abiraterone, and enzalutamide, and all-grade hypertension for nintedanib; high- and all-grade arterial thromboembolism (includes cardiac and/or cerebral events) for bevacizumab and abiraterone, high-grade arterial thromboembolism for trastuzumab, and all-grade arterial thromboembolism for sorafenib and tamoxifen; high- and all-grade venous thromboembolism (VTE) for lenalidomide and thalidomide, high-grade VTE for cetuximab and panitumumab, and all-grade VTE for bevacizumab; high- and all-grade left ventricular ejection fraction decline or congestive heart failure for bevacizumab and trastuzumab, and all-grade left ventricular ejection fraction decline/congestive heart failure for pazopanib and sunitinib; and all-grade corrected QT interval prolongation for vandetanib.

Conclusions

Our review provides an accessible summary of the cardiovascular toxicity of targeted therapy to assist clinicians and patients when managing cardiovascular health.
BRCA1/2 Mutation Status Impact on Autophagy and Immune Response: Unheralded Target
Authors: Morand Susan , Stanbery Laura , Walter Adam , Rocconi Rodney P , Nemunaitis John
Published: August 2020

BRCA1 and possibly BRCA2 proteins may relate to the regulation of autophagy. Autophagy plays a key role in immune response from both a tumor and immune effector cell standpoint. In cells with BRCA mutations, increased autophagy leads to elevated expression of major histocompatibility complex class II but may cause subclonal neoantigen presentation, which may impair the immune response related to clonal neoantigen visibility. We review evidence of BRCA1/2 regulation of autophagy, immune response, and antigen presentation.
An Endovascular Surgery Experience in Far-Forward Military Healthcare—A Case Series
Authors: Coughlin Daniel J , Boulter Jason H , Miller Charles A , Curry Brian P , Glaser Jacob , Fernandez Nathanial , Bell Randy S , Schuette Albert J
Published: August 2020

Introduction

The advancement of interventional neuroradiology has drastically altered the treatment of stroke and trauma patients. These advancements in first-world hospitals, however, have rarely reached far forward military hospitals due to limitations in expertise and equipment. In an established role III military hospital though, these life-saving procedures can become an important tool in trauma care.

Materials and Methods

We report a retrospective series of far-forward endovascular cases performed by 2 deployed dual-trained neurosurgeons at the role III hospital in Kandahar, Afghanistan during 2013 and 2017 as part of Operations Resolute Support and Enduring Freedom.

Results

A total of 15 patients were identified with ages ranging from 5 to 42 years old. Cases included 13 diagnostic cerebral angiograms, 2 extremity angiograms and interventions, 1 aortogram and pelvic angiogram, 1 bilateral embolization of internal iliac arteries, 1 lingual artery embolization, 1 administration of intra-arterial thrombolytic, and 2 mechanical thrombectomies for acute ischemic stroke. There were no complications from the procedures. Both embolizations resulted in hemorrhage control, and 1 of 2 stroke interventions resulted in the improvement of the NIH stroke scale.

Conclusions

Interventional neuroradiology can fill an important role in military far forward care as these providers can treat both traumatic and atraumatic cerebral and extracranial vascular injuries. In addition, knowledge and skill with vascular access and general interventional radiology principles can be used to aid in other lifesaving interventions. As interventional equipment becomes more available and portable, this relatively young specialty can alter the treatment for servicemen and women who are injured downrange.
Do model emission line galaxies live in filaments at z ∼ 1?
Authors: Gonzalez-Perez V , Cui W , Contreras S , Baugh C M , Comparat J , Griffin A J , Helly J , Knebe A , Lacey C , Norberg P
Published: August 2020

Current and future cosmological surveys are targeting star-forming galaxies at z ∼ 1 with nebular emission lines. We use a state-of-the-art semi-analytical model of galaxy formation and evolution to explore the large-scale environment of star-forming emission line galaxies (ELGs). Model ELGs are selected such that they can be compared directly with the DEEP2, VVDS, eBOSS-SGC, and DESI surveys. The large-scale environment of the ELGs is classified using velocity–shear–tensor and tidal–tensor algorithms. Half of the model ELGs live in filaments and about a third in sheets. Model ELGs that reside in knots have the largest satellite fractions. We find that the shape of the mean halo occupation distribution of model ELGs varies widely for different large-scale environments. To interpret our results, we also study fixed number density samples of ELGs and galaxies selected using simpler criteria, with single cuts in stellar mass, star formation rate, and [O ii] luminosity. The fixed number density ELG selection produces samples that are close to L[O ii] and SFR-selected samples for densities above 10−4.2 h3 Mpc−3. ELGs with an extra cut in stellar mass applied to fix their number density, present differences in sheets and knots with respect to the other samples. ELGs, SFR, and L[O ii] selected samples with equal number density have similar large-scale bias but their clustering below separations of 1h−1 Mpc is different.
Chirp mass and spin of binary black holes from first star remnants
Authors: Kinugawa Tomoya , Nakamura Takashi , Nakano Hiroyuki
Published: August 2020

We performed Population III (Pop III) binary evolution using population synthesis simulations for seven different models. We found that Pop III binaries tend to be binary black holes (BBHs) with chirp mass Mchirp ∼ 30 M⊙ and they can merge in the present day, due to a long merger time. The merger rate densities of Pop III BBHs at z = 0 are in the range 3.34–21.2 $\rm yr^{-1}\,Gpc^{-3}$ which is consistent with the Advanced Laser Interferometer Gravitational Wave Observatory (aLIGO)/Advanced Virgo (aVIRGO) result of 9.7–101 $\rm yr^{-1}\,Gpc^{-3}$. These Pop III binaries might contribute some portion of the massive BBH gravitational wave (GW) sources detected by aLIGO/aVIRGO. We also calculated the redshift dependence of Pop III BBH mergers. We found that Pop III low-spin BBHs tend to merge at low redshift, while Pop III high-spin BBHs merge at high redshift, which can be confirmed by future GW detectors such as Einstein Telescope (ET), Cosmic Explorer (CE), and DECi-hertz Interferometer Gravitational wave Observatory (DECIGO). These detectors can also check the redshift dependence of the BBH merger rate and spin distribution. Our results show that, except for one model, the mean effective spin 〈χeff〉 at z = 0 lies in the range 0.02–0.3, while at z = 10 it is 0.16–0.64. Therefore, massive stellar-mass BBH detection by GWs will be key for stellar evolution study in the early Universe.
Modelling R Coronae Borealis stars: effects of He-burning shell temperature and metallicity
Authors: Crawford Courtney L , Clayton Geoffrey C , Munson Bradley , Chatzopoulos Emmanouil , Frank Juhan
Published: August 2020

The R Coronae Borealis (RCB) stars are extremely hydrogen-deficient carbon stars that produce large amounts of dust, causing sudden deep declines in brightness. They are believed to be formed primarily through white dwarf mergers. In this paper, we use mesa to investigate how post-merger objects with a range of initial He-burning shell temperatures from 2.1 to 5.4 × 108 K with solar and subsolar metallicities evolve into RCB stars. The most successful model of these has subsolar metallicity and an initial temperature near 3 × 108 K. We find a strong dependence on initial He-burning shell temperature for surface abundances of elements involved in the CNO cycle, as well as differences in effective temperature and radius of RCBs. Elements involved in nucleosynthesis present around 1 dex diminished surface abundances in the 10 per cent solar metallicity models, with the exception of carbon and lithium that are discussed in detail. Models with subsolar metallicities also exhibit longer lifetimes than their solar counterparts. Additionally, we find that convective mixing of the burned material occurs only in the first few years of post-merger evolution, after which the surface abundances are constant during and after the RCB phase, providing evidence for why these stars show a strong enhancement of partial He-burning products.
3 In-Hospital Child Mortality after Consolidation of Two Pediatric Intensive Care Units
Authors: Parvez Sehar , Soper Juliet
Published: August 2020

Background

While high-volume specialized Pediatric Intensive Care Units (PICUs) increase the survival of critically ill children, the benefits of consolidating PICUs to a single site may be outweighed by the need to transport critically ill children when the area serviced has a low population density and vast geography.

Objectives

This study seeks to describe the impact of PICU consolidation on mortality of children from the southern part of a Canadian province, after presentation to nearest hospital, following consolidation of PICUs to a single more centrally located PICU.

Design/Methods

We conducted a retrospective chart review of children with a primary residence in the southern part of the province, who died between January 2008 and December 2017 after presentation to the nearest hospital. Children who died prior to presentation to hospital or did not have return of spontaneous circulation at any time after presentation were excluded from analysis. Child demographics, year of death, cause of death, and Pediatric Risk of Mortality III (PRISM III) score, and duration and type of treatments provided were abstracted from health records. Population census data was obtained from the 2016 Canada Census. Deaths were grouped for analysis according to the child’s place of residence within three specific administrative areas. Nonparametric Mann Whitney U-test was used for descriptive analysis.

Results

Eighty-six (86) children from the southern part of the province died following presentation to the nearest hospital during the 10-year study period. The observed population rate of in-hospital deaths was 6.8 per 100,000 children per year before consolidation and 8.5 per 100,000 children per year after consolidation of PICU services. Variation in the population rate of in-hospital deaths before and after consolidation of PICUs was observed between administrative areas (p=0.016). The data did not appear to show an association with urban or non-urban areas. Children who died after consolidation were more likely to receive pain relief (p=0.013), and palliative care consultation (p=0.005) than those who died prior to consolidation. No change in acuity at presentation to hospital or cause of death was observed following PICU consolidation (p=0.3).

Conclusion

This study did not find evidence of a change in the rate of in-hospital child deaths per 100,000 children following consolidation of PICU services in a Canadian province.
4 Saline-lock versus continuous infusion: maintaining peripheral intravenous catheter access in children
Authors: Yeung Frances , Taheri Sepideh , Miller Michael , Ojha Rahul , McKelvie Brianna , Bock Dirk , Poonai Naveen , Cameron Saoirse
Published: August 2020

Background

Peripheral intravenous catheter (PIVC) insertion is a painful and invasive procedure performed on most paediatric patients. In children, PIVCs are maintained by either a continuous infusion of fluid “to keep vein open” (TKVO) or a saline-lock (SL). There is little uniformity between pediatric centres as to which method is used, and evidence is required to decide which method, if any, best maintains PIVC access.

Objectives

The primary objective was to compare duration of functional PIVC patency between TKVO and SL in children. Secondary objectives included assessing PIVC-related complications and patient/caregiver satisfaction.

Design/Methods

This prospective, time-allocated trial enrolled eligible patients from newborn to 17 years of age admitted to our pediatric ward. Patients enrolled in the first 3 months were assigned to TKVO, and patients in the latter 3 months were assigned to SL. Time of PIVC insertion and removal, PIVC-related complications, and satisfaction surveys were collected. Independent t-tests and chi-square tests were used to compare differences between arms for continuous and categorical outcomes, respectively.

Results

Complete PIVC data was available on 172 (n=85 TKVO, n=87 SL) of 194 enrolled patients. The mean (SD) duration of PIVC patency was 41.68 (41.71) hours in the TKVO group, and 44.05 (41.46) hours in the SL group, which was not statistically significant (p=0.71). There were no significant differences in complication rates or overall patient/caregiver satisfaction between the two groups. One patient in the TKVO group had their PIVC removed due to risk of strangulation from tubing.

Conclusion

There were no significant differences between TKVO and SL in the duration of PIVC patency in our pediatric population. This is consistent with previous results in neonates. There were also no significant differences in complication rates and overall patient/caregiver satisfaction. Overall, SL is a safe and reasonable alternative to TKVO in maintaining PIVC patency in children.
6 Factors associated with treatment failure of high flow nasal cannula (HFNC) among children with bronchiolitis: a single centre retrospective study
Authors: D’Alessandro Michelle , Vanniyasingam Thuva , Patel Ashaka , Gupta Ronish , Giglia Lucy , Federici Giuliana , Wahi Gita
Published: August 2020

Background

Bronchiolitis is the most common viral lower respiratory tract infection in children under two years of age and is the leading cause of hospital admission for children under the age of one year. Respiratory support for bronchiolitis with high flow nasal cannula (HFNC) is increasingly being used outside of critical care areas and in community hospitals. It is important to understand the patient factors associated with HFNC treatment failure in order to identify which patients are at higher risk for requiring escalation of respiratory support and transfer to a pediatric critical care centre.

Objectives

The primary objective of this study was to evaluate the patient characteristics that are associated with HFNC treatment failure in bronchiolitis.

Design/Methods

We completed a retrospective review of patients under 24 months of age with a clinical diagnosis of bronchiolitis admitted to a single tertiary level children’s hospital for supportive management with HFNC between January 2014 and December 2018. Patients who were mechanically ventilated or on non-invasive positive pressure ventilation prior to the initiation of HFNC during their hospital stay were excluded. HFNC treatment failure was the primary endpoint of the study, with treatment failure defined as escalation to non-invasive positive pressure or invasive mechanical ventilation. Multivariable logistic regression analysis was used to identify the patient demographic, clinical, and biochemical parameters associated with HFNC failure.

Results

Four hundred and thirty-five patient charts were identified, of which 208 patients met inclusion criteria for the study. Of these patients, 61 (29%) were classified as HFNC treatment failures. The likelihood of failing HFNC support was reduced with older age (OR 0.89; 95% CI 0.81, 0.97; p= 0.011) and greater time spent on HFNC (OR 0.94; 95% CI 0.92, 0.96; p<0.001). Patients with a Modified Tal score greater than 5 at 4 hours of HFNC treatment had a greater likelihood of failing HFNC support (OR 2.81; 95% CI 1.04, 7.64; p= 0.042).

Conclusion

This was the first study to examine predictors of HFNC failure among Canadian children with bronchiolitis. We found that patient age, time spent on HFNC, and severity of bronchiolitis as defined using a Modified Tal score were associated with HFNC failure. These patient factors should be considered when initiating HFNC for bronchiolitis, and may identify patients at risk for escalation of respiratory support, warranting earlier referral to pediatric critical care centres.
11 “Green Means Go”: Creation of a Discharge Checklist Tool for Patients with Bronchiolitis
Authors: Buba Melanie , Hall Kerry-Lynne
Published: August 2020

Background

A consistent and predictable discharge process is difficult to achieve, yet essential for good patient flow, appropriate resourcing, and safe patient care. At our institution, physicians predicted the estimated discharge date (EDD) for patients with bronchiolitis with 70.5% accuracy (January – March 2019). A key driver of this unpredictability is a lack of consensus on “medical discharge readiness” criteria across providers, which also has impacts on communication within the health care team and with patients and families.

Objectives

1. To improve the ability to predict discharge date for patients with bronchiolitis by implementing a standardized medical discharge criteria checklist tool for one month (April 2019).

2. To more fully engage nurses in their patients’ care by improving transparency and accuracy of information about discharge.

3. To increase patient and family satisfaction with the discharge process.

Design/Methods

Meetings with key stakeholders determined drivers of discharge. Data on national practice variation in the management of patients with bronchiolitis was reviewed and informed the creation of a set of medical discharge criteria. Criteria were reviewed and accepted by the Division of Pediatric Medicine and presented to key stakeholders for feedback. Patient inclusion and exclusion criteria were developed. Feedback on the intervention was sought via surveys to physicians, nurses and patients/families.

Results

There was significant improvement (70.5% to 92.3%) in accuracy of predicting EDD with use of the medical discharge criteria checklist tool. There was also a reduction in length of stay. There were no patient bounce-backs to ED or patient readmissions. There was high satisfaction and support of the checklist tool from nursing and caregivers.

Conclusion

The development of standardized medical discharge criteria for patients with bronchiolitis is a safe and effective way to improve predictability, transparency, communication and patient flow, while enhancing engagement of the health care team and patient and family satisfaction. Its use is also associated with a reduced length of stay. Future directions include integrating the checklist tool into the electronic health record and moving towards a nurse-facilitated discharge process. Exploring and addressing non-medical barriers to discharge should also be a priority.
13 Evaluating Potential Overuse of Intravenous Hydration in Patients Hospitalized with Bronchiolitis
Authors: Langlois Vénitia , Sainte-Marie-Lestage Chloé , Bernard-Bonnin Anne-Claude , Lucas Nathalie , Bédard Pascal , Essouri Sandrine , Evangeliou Helena
Published: August 2020

Background

Bronchiolitis is the primary cause of hospitalization in children during the first year of life. Respiratory support and hydration are the two pillars of management. Practice guidelines for bronchiolitis (NICE and CPS) recommend nasogastric (NG) hydration before intravenous (IV) fluids if oral hydration cannot be maintained. However, IV hydration remains the primary mode of hydration at our tertiary care pediatric centre.

Objectives

This is a resource stewardship project aiming to evaluate the baseline use of IV versus NG hydration in children 0-15 months hospitalized for bronchiolitis and requiring supplemental hydration. The secondary objective is to evaluate potential barriers to NG hydration for these children.

Design/Methods

Data was collected retrospectively for the 2017-2018 bronchiolitis season. A survey was sent to all the pediatric emergency (ED) physicians and nurses, pediatric hospitalists, ED fellows, pediatric residents and ward nurses.

Results

Among eligible patients (n=95), IV hydration was prescribed 52% of the time, compared to 48% NG hydration. Ninety-six percent (47/49) of IV hydration was initiated in the ED, while only 4% (2/49) was initiated on the ward. Among patients who began receiving hydration in the ED (80/95, or 84%), 41% (33/80) were hydrated via NG and 59% (47/80) by IV.

In the survey, while 92% (57/62) of responding physicians claimed to be aware of national guidelines for bronchiolitis, only 67% (42/62) said that NG was the recommended mode of hydration. Among ED practitioners, 56% (19/34) were up-to-date on the recommendation. Two-thirds of all respondents (physicians and nurses) felt that NG hydration would be more acceptable to parents. Among nurses, 84% (38/45) felt that IV installation was a longer procedure to complete. Despite the existence of a local order set indicating NG hydration as the preferred hydration method, only 64% (40/62) of physicians were aware of its existence, and only 23% of these (9/40) actually use the guideline. Main reasons of disuse included forgetting the guideline exists and it not being easily available. In contrast, 93% of nurses were aware of the local guideline.

Conclusion

Intravenous hydration is overused among patients hospitalized with bronchiolitis at our centre, and the ED is the main setting where this occurs. There is a discrepancy between physicians’ theoretical knowledge of hydration guidelines and the application of these in reality. Barriers to the use of NG hydration can be amenable to a quality improvement (QI) intervention targeting improved knowledge and use of our local guideline, and this will be our focus going forward.
15 PAEDIATRIC TUBERCULOSIS MANAGED AT A CANADIAN CHILDRENS HOSPITAL: RELATIONSHIP TO BIRTHPLACE AND TRAVEL HISTORY
Authors: Elhafid Melanie , Morris Shaun , Kourdi Haifa , Waters Valerie , Lam Ray , Kitai Ian
Published: August 2020

Background

There are limited data about the relationship of child’s birthplace, parents’ birthplace, and travel history to paediatric tuberculosis (TB) acquisition and disease phenotype in Canada. Travel history is not routinely collected by public health authorities for cases of TB in Canada.

Objectives

The objective of this study is to investigate the association of paediatric TB acquisition and disease phenotype at a metropolitan Canadian children’s hospital with child’s birthplace, parents’ birth place, and travel history.

Design/Methods

We reviewed prospectively collected TB clinic data (which include travel histories) and records of patients aged 0-17 years managed for active TB disease at a children’s hospital ambulatory TB clinic between January 1, 2002 and December 31, 2018.

Results

Two hundred and twenty six cases were identified, of which 116 (51%) were Canadian-born and 110 (49%) were foreign born children. Of the Canadian-born cases, only one case had parents who were both Canadian-born. In comparison to foreign-born patients, Canadian-born patients were more likely to have a history of travel to a TB-endemic country (63/104) [61%] versus (25/103) [24%], odds ratio [OR] 4.8; 95% confidence interval [CI] 2.6-8.7 p<0.001. Canadian-born patients were also more likely to have a known index case (80/116) [69%] versus foreign-born patients (23/110) [21%], OR 8.4; 95% CI 4.5-15.4, p<0.001. For Canadian-born patients, those without a known index case were more likely to have a history of travel to a TB-endemic country than those with a known index case (28/34) [82%] versus (35/70) [50%], [OR] 4.7 95% CI 1.7-12.7, p=0.02. Compared to Canadian-born patients, foreign-born patients had more extrapulmonary disease (48/109) [44%] versus (19/114) [17%], OR 3.9; 95% CI 2.1-7.3, p <0.001.

Conclusion

Canadian-born children often acquired TB through contact with an infectious source in Canada. However, travel was likely important in a significant minority of cases, especially in Canadian-born children without a known index case. Post-immigration travel may also have been the source of TB in some foreign-born individuals. This would reduce the effectiveness of screening children for TB infection upon immigration. Strategies to prevent and detect travel-related TB are needed to reduce paediatric TB in areas with high immigration rates.
18 Lyme disease as an emerging cause of Seventh Cranial Nerve Palsy (“Bell’s palsy”) in Nova Scotia
Authors: LeBlanc Julia , Young Michael , Wood Ellen , MacKinnon-Cameron Donna , Langley Joanne
Published: August 2020

Introduction/Background

Lyme disease, a tick-borne zoonosis caused by the bacterium Borrelia burgdorferi, has emerged in Nova Scotia (NS) as a common illness. Since 2002 when Lyme disease was first diagnosed in NS, >1000 cases have been reported. Seventh cranial nerve palsy (CNP-7) is said to be the most common presentation of early disseminated Lyme disease in children in endemic areas.

Objectives

We aimed to determine the frequency of CNP-7 in NS and if physicians are considering Lyme disease as an etiology.

Design/Methods

A retrospective review of health records of children seen at the IWK Health Centre from 2000-2018 who were ≤18 years of age with an ICD-9 or 10 diagnosis of Bell’s palsy (CNP-7) was conducted. CNP-7 due to local infection, trauma, malignancy, or systemic neurologic disease was excluded.

Results

Of 237 ICD “Bell’s palsy” diagnoses, 66 cases were eligible, of which 60.6 % (n=40) were female. The median age was 10 years (range 0-16). Five cases of Lyme disease-associated CNP-7 were recognized (7.6%), all since 2013. No bilateral CNP-7 occurred; 59.1% of cases were on the left. Most children presented within 3 days of symptom onset (84.8%) to the emergency department (95.4%), and 56.1% subsequently saw a pediatric neurologist. The most common associated symptom with CNP-7 was headache (22.7%). Lyme disease was considered in the differential diagnosis in 34.8 % (n=23) of cases, and only since 2012. Systemic steroids were prescribed to 51.5 % (34/66) of children in the emergency department, for durations varying from 1 to 10 days. The most common steroid course length was 5 days. Antimicrobials were prescribed for 18 (27.3%) children including acyclovir, beta lactams and tetracyclines.

Resolution of the facial palsy findings was documented in 45 children, of whom 36 (54.5%) had complete resolution and 9 (13.6%) had partial resolution. Four children with Lyme disease associated CNP-7 had complete resolution, and one had partial resolution.

Conclusion

There does not appear to be a standard approach to diagnosis and management of CNP-7 in this pediatric health centre. Lyme disease is not regularly considered in the differential diagnosis, which is surprising given the high incidence of Lyme disease in NS. These findings will be shared with health care providers most likely to see CNP-7 in order to develop a standard algorithm to the initial presentation of 7th cranial nerve palsy in children.
22 Parental Perceptions and Patterns of Cannabis Use During Pregnancy and Breastfeeding at a Canadian Tertiary Obstetrics Centre
Authors: Manning Sarah , Drover Anne
Published: August 2020

Background

On October 17th, 2018, recreational cannabis use became legalized in Canada. Tetrahydrocannabinol (THC) is the main psychoactive compound in cannabis. It has the ability to cross the placenta and enter fetal tissues during pregnancy and accumulate in breast milk postpartum. There is limited research on the long-term effects of cannabis use, particularly on the developing brain. Canadian guidelines recommend that women who are thinking about becoming pregnant, are pregnant, or breastfeeding should abstain from using cannabis.

Objectives

The objective of this study was to investigate parental perceptions and patterns of cannabis use during the pre- and post-natal periods.

Design/Methods

Participants were recruited from the women’s health unit at a tertiary care centre; a total of 102 patients or partners of patients who were currently pregnant or less than 6 months post-partum were enrolled in the study. Participants consented to complete an anonymous, online questionnaire including previously validated demographic questions and newly developed questions on cannabis use during pregnancy and breastfeeding. Chi-square tests were used for data analysis.

Results

Overall, 5.0% of pregnant women and 6.3% of breastfeeding women used cannabis daily or weekly. Women who did not complete high school were significantly more likely to use cannabis during pregnancy than women who completed higher levels of education (p < 0.001). Additionally, women who smoked cigarettes or vaped tobacco during pregnancy were significantly more likely to use cannabis during pregnancy (p < 0.001; p < 0.001). Among all participants, 22.6% and 30.4% believed there was no harm or were unsure of the harm associated with cannabis use during pregnancy and breastfeeding, respectively. Around half of the women who used cannabis during pregnancy or breastfeeding indicated that knowledge of the possible effects on the fetus or child would decrease their cannabis use. The majority of participants reported obtaining their information on cannabis use during breastfeeding from the internet (34.0%); while only 8.1% reported receiving information from a family doctor, 6.5% from an OBGYN, and 1.6% from a pediatrician. Legalization of cannabis had no reported effect on cannabis use during pregnancy and breastfeeding for the majority of participants.

Conclusion

It is clear that parents lack information about the safety of cannabis use during pregnancy and breastfeeding. Perinatal counselling should put an emphasis on educating parents on the risks associated with cannabis use during fetal development. In addition, given the overwhelming benefits of breastfeeding, harm reduction approaches to cannabis use while breastfeeding should be investigated.
30 Predicting gestational age improves newborn screening for congenital adrenal hyperplasia
Authors: Jomaa Danny , Henderson Matthew , Hawken Steven , Chakraborty Pranesh
Published: August 2020

Background

Newborn screening for congenital adrenal hyperplasia is performed using a two-tier approach. The first tier involves comparison of neonate 17-hydroxyprogesterone levels to gestational age (GA)-based thresholds. When GA is unreported, which occurs in approximately 5% of births, birth weight (BW)-based thresholds are the only available option. However, these have a lower specificity and result in more false positive results. Recently, a predictive model was developed to estimate GA based on newborn demographics and the screening analytes measured in a blood sample.

Objectives

The objective of this study was to determine whether supplying a predicted GA to newborns with unreported GA, and subsequent GA-based screening, has a higher positive predictive value than BW-based screening.

Design/Methods

Screening data was obtained for approximately 700,000 births that occurred in Canada between 2011 and 2015. Predicted GA was calculated using a model composed of demographic and screening analyte factors. The positive predictive values of BW- and predicted GA-based screening were calculated for newborns with unreported GA. A sequential approach was then developed whereby newborns with unreported GA were first screened by BW-based screening. Newborns that screened positive were then supplied with their predicted GA and screened using GA-based thresholds.

Results

First-tier CAH screening using GA-based 17-hydroxyprogesterone thresholds had a higher positive predictive value than using BW-based thresholds (1.30% vs. 0.82%). In the study time period, 3.61% of newborns had an unreported GA. For these newborns, predicted GA-based screening had a higher positive predictive value than BW-based screening (0.83% vs. 0.76%) and correctly identified the 2 infants with CAH whose GA was unreported. A sequential screening approach was then used: BW-based screening and, for the screen positive population, predicted GA-based screening. This further increased the positive predictive value compared to BW-based screening (0.95% vs. 0.76%), reduced the false positive rate, and correctly identified true positive cases.

Conclusion

Reducing the false positive rate of CAH screening is important to prevent unnecessary second-tier screening and referrals. For newborns with unreported GA (4-5% of all births), BW-based screening is the only currently available approach. However, this approach has a poor specificity and a high false positive rate compared to GA-based screening. This study is the first to demonstrate an alternative screening strategy with a higher positive predictive value for newborns with unreported GA.
45 Helping the Helpers: Peer Critical Incident Stress Management for NICU Health Care Providers to Improve Resilience, Burnout and Patient Safety
Authors: Lifeso Natasha , Hicks Matthew , Joynt Chloe
Published: August 2020

Introduction/Background

Health care providers in neonatal intensive care units (NICU) experience critical or distressing events that can overwhelm their usual coping skills and lead to significant stress. Ineffective support for health care providers dealing with critical incidents can lead to poor unit resilience, staff burnout and compromised patient care behaviours. A formalized peer program and process to address critical workplace incidents and support care providers, “Critical Incident Stress Management (CISM)” is used in many first responder professions. While there is growing interest in implementing peer CISM teams in critical care units, there is a lack of research describing the impact of CISM in NICU.

Objectives

This study examined the effect of implementing a multidisciplinary NICU health care provider peer CISM team on resilience, burnout, and team/safety culture in a tertiary NICU.

Design/Methods

Multidisciplinary team members were peer selected and formally CISM trained. Change management strategies were employed to introduce CISM to the NICU. All health care providers were invited to complete an anonymous online or paper survey before and 1 year after NICU CISM team implementation. The survey contained validated measures of resilience, burnout, and team/safety culture that were analyzed pre and post intervention.

Results

The response rate pre-intervention was 66% (114/172 staff) and 32% post (60/186 staff). Stress recognition significantly improved as fewer staff reported being less effective at work when feeling stressed post incident (74% vs 61%, pre and post CISM respectively, p<0.05) (Table 1). Fewer staff reported feeling burned out from their work (41% vs 31%, p=0.4), trending towards improved resilience (Table 1). Communication in the NICU significantly improved as staff indicated debriefing methods met their needs (38% vs 57%, p<0.05) and felt comfortable speaking up about safety concerns (66% vs 78%) (Table 1). Post-intervention, despite feelings of increased workload indicated by a significant decrease in agreement that “NICU staff levels were sufficient for patient load” (54% vs 33%, p<0.001), a majority of staff reported a supportive environment in the NICU (59% vs 77%, p=0.08) (Table 1). Work culture significantly improved as staff felt rewarded and recognized for improving quality (13% vs 31%, p<0.05) (Table 1).

Conclusion

Implementation of a peer CISM team led to improved NICU care provider resilience, stress recognition, and team culture, all of which can mitigate the effects of increased patient load. Findings from this research and knowledge gained from the CISM implementation process should be shared with other health care environments.
50 Bridging the gap between education and health: What youth need educators to know about chronic pain
Authors: McMahon Casey , Bonkowski Rylie , Hoehn Marty , Baerg Krista
Published: August 2020

Background

Chronic pain is common and affects 20% of children and youth. Those with chronic pain often have a difficult time regularly attending school, with up to 50% of children and youth with chronic pain missing some school. Specific accommodations that benefit youth are unknown. Nearly half of parents of youth with chronic pain report their child’s grades dropped since pain onset. Both parents and youth report “moderate levels of interference” with learning. Most common accommodations include being sent to the nurse, being sent home and receiving extensions on assignments. While these strategies may be helpful for pain conditions expected to resolve, strategies that support staying in and succeeding at school are required for youth with chronic pain.

Objectives

This study aims to determine what educators need to know to best support youth with chronic pain in the academic setting. More specifically, 1) to determine what youth with chronic pain, parents of youth, educators, and healthcare professionals want educators to know about supporting students with chronic pain, and 2) to describe health professionals’ and educators’ attitudes and knowledge of pediatric chronic pain.

Design/Methods

Inclusion criteria include youth age 12-25 years with chronic pain and parents, health professionals and educators of youth with chronic pain. The recruitment strategy includes distribution of the survey via the Saskatchewan pediatric chronic pain clinic research contact lists, the Canadian Paediatric Society Section of Community Paediatrics listserve and social media. This online cross-sectional survey includes participant demographics and questions about accommodations noted to be helpful for youth with chronic pain. In addition, educator and health professional surveys include the 26-item Chronic Pain Myth Scale (CPMS).

Results

The study group includes 87 participants, 26 youth, 18 family/friends, 19 educators, and 24 health professionals. Some suggested school accommodations include: access to technology in class, teachers providing notes for students, education on chronic pain for teachers and students, and improved communication and collaboration between the youth, their healthcare team and educators. The majority of health professionals and educators report some knowledge, positive beliefs and attitudes towards people suffering from chronic pain (M=3.03, SD= .34).

Conclusion

Chronic pain is common and affects school attendance and achievement. Suggestions for accommodations to help those with chronic pain in the academic setting are made. Educators and health professionals indicated varying levels of knowledge, attitudes and beliefs, with some educators indicating they would like to receive education about chronic pain. Improved communication between school-based pupil support teams and health care teams is warranted.