bluuebunny/crossref_metadata_2025 huggingface dataset:
58 Overweight and obesity in children with autism spectrum disorder: Findings from primary care electronic medical records
Authors: Kinlin Laura M , Carsley Sarah , Keown-Stoneman Charles , Saunders Natasha , Tu Karen , Zwaigenbaum Lonnie , Birken Catherine S
Published: August 2020

Introduction/Background

Paediatric overweight and obesity are important public health problems worldwide. Children with autism spectrum disorder (ASD) may be at increased risk compared to their typically-developing peers; however, prevalence estimates in ASD have varied widely and existing studies have largely been limited by use of an external comparison group.

Objectives

To compare prevalence of overweight and obesity in children and youth (<19 years of age) with and without ASD, using electronic medical record data from paediatric primary care visits.

Design/Methods

This was a cross-sectional analysis of EMRPC (Electronic Medical Records Primary Care) data, representing 385 family physicians in 43 clinics in Ontario, Canada. Age- and sex-standardized body mass index (BMI) z-scores were calculated using abstracted heights and weights from the most recent visit between January 2011 and December 2015. Weight status was determined using World Health Organization growth reference standards. ASD was defined using a previously-validated algorithm in EMRPC, based on an ASD-related term in the ‘Cumulative Patient Profile.’ Chi-square test statistics and multinomial logistic regression were used to compare weight status of those with and without ASD.

Results

In total, 44,625 children and youth were included, 632 [1.42%] with ASD. Distribution of weight status was significantly different between those with and without ASD (p<0.001) [Table 1]. Compared to their typically-developing peers, children with ASD had significantly higher odds of overweight (unadjusted odds ratio [OR] 1.52; 95% confidence interval [CI] 1.24-1.87), obesity (unadjusted OR 2.55 (2.00-3.26) and severe obesity (unadjusted OR 3.09; 95% CI 2.08-4.60); these associations persisted after adjusting for sex, age, neighborhood income quintile and rural residence (Table 2).

Conclusion

Data from a large primary care database suggest that children with ASD are at substantially increased risk of overweight, obesity and severe obesity. Findings support the need for anticipatory guidance, prevention and management strategies specific to this clinical population. Future work will aim to better understand at what age differences in weight status emerge, and what nutritional, behavioural, or medical factors differentially affect weight status in the ASD population.
62 Nutritional assessment of children in Hartley Bay (Gitga’at), BC
Authors: McIntyre Jen , Karakochuk Crystal , Meuter Christa , Duffy Damian , Sauvé Laura
Published: August 2020

Background

Hartley Bay is a small, remote Gitga’at community. As part of “Brighter Smiles”, a multidisciplinary child health partnership between the Gitga’at Nation and BC Children’s Hospital, the community requested a quality assurance project to describe the nutritional status of its children and assess the impact of the existing school based nutrition program.

Objectives

The community wished to explore ways in which the existing nutrition program could be optimized to further meet the nutritional needs of its children in terms of macronutrient, micronutrient and meal content and to explore food beliefs and values.

Design/Methods

Gitga’at health leadership guided the design of the study and community approval was sought at an early stage. All Hartley Bay families with children aged 5-18 were invited to participate. With the support of the teachers, a 24-hour dietary recall survey was completed online during school time using the WEB-Q software program. Nutritional information was then analyzed and compared. Anthropometric data (heights, weights, BMI and blood pressures) were collected during routine clinic visits in September 2018, compared with population based norms and analyzed.

Results

Anthropometric data was collected for 23/30 school aged children. In terms of anthropometrics, 45.5% of girls and 16.7% of boys had a body mass index (BMI) in the healthy range (3rd-85th percentile). Results showed 18.2% girls and 25% of boys had a BMI in the overweight range (85th – 97th percentile), while 36.4% of girls and 58.3% of boys respectively were in the obese or severely obese range. Blood pressures demonstrated that 75% of females and 62.5% of males were normotensive (systolic BC <87%ile). There are many accomplishments of the community highlighted in this study including attitudes towards traditional foods and harvesting, openness to try new foods and spending meal time with family. Four in 18 students were meeting the recommended 5 servings of vegetables/fruits per day. The average intake of sodium for 9-13 year olds was 3g/day (recommended upper limit is 2.2g/day). For 14-18 year olds the average sodium intake was 4.6g/day (recommended upper limit is 2.3g/day). One in 18 students met adequate intake for calcium, 2/18 for fibre and 13/18 for vitamin D. The majority of children in this community are obtaining the recommended percentage energy from fats, carbohydrates and protein.

Conclusion

A significant proportion of Hartley Bay children had anthropometric measurements suggesting they were at risk for long term negative health outcomes. The study also indicated areas to improve, with suboptimal micronutrient intake. Successes of the community were also highlighted. The data was presented to Hartley Bay health staff, Elders and community members so that it can be used collaboratively by the health staff and community leadership to work on community-designed programs for health promotion.
72 Validating MyHEARTSMAP, an emergency psychosocial self-assessment and management tool, among youth with minor traumatic brain injuries or minor orthopaedic injuries seen in the Paediatric Emergency Department
Authors: Lamoureux Erik , Ishikawa Takuro , Yeates Keith , Beauchamp Miriam , Craig William , Gravel Jocelyn , Zemek Roger , Doan Quynh
Published: August 2020

Background

Fewer than 20% of the estimated 1.2 million Canadian youths living with mental health (MH) concerns receive adequate care. Paediatric emergency department (PED) visits related to MH are increasing across North America. The online self-assessment tool, MyHEARTSMAP, was developed to facilitate screening of MH concerns in the PED and general practice. MyHEARTSMAP assesses 10 psychosocial areas, mapping to four domains of MH (Psychiatry, Function, Social, and Youth Health) to provide domain-specific recommendations for patient management (Figure A).

Objectives

We evaluated the convergent validity of MyHEARTSMAP when compared to established psychosocial self-assessment tools: Paediatric Quality of Life (PedsQL) and Strengths and Difficulties Questionnaire (SDQ).

Design/Methods

We conducted a cross-sectional study among youths and parents enrolled in a larger cohort study: Advancing Concussion Assessment in Paediatrics (A-CAP). Participants were children aged 8 to 16 years old with mild traumatic brain injury or orthopaedic injury and their parents. Participants were recruited from two PEDs in Alberta and British Columbia and were asked to complete MyHEARTSMAP, in addition to the PedsQL and SDQ completed in their A-CAP study procedures. We evaluated three MH domains from MyHEARTSMAP (PSYCHIATRY FUNCTION, AND SOCIAL) to their corresponding score sections in PedsQL (EMOTIONAL, SCHOOL, and SOCIAL) and SDQ (EMOTIONAL, none, and CONDUCT and PEER). We calculated Pearson correlation coefficients between these corresponding domains and sections.

Results

We recruited 40 child and parent pairs from Alberta and 82 from BC. The children were on average aged 12.6 years old (SD 2.2) and 44% were female. The tools screened participants as “at-risk” for various MH concerns at a rate of 26.7% to 60.8% for MyHEARTSMAP, 2.5% to 13.9% for PedsQL, and 12.3% to 16.0% for SDQ. Overall, MyHEARTSMAP was moderately correlated with PedsQL (mean ±95% CI: r = 0.405±0.151) and SDQ (mean ±95% CI: r = 0.322±0.162). Correlations (±95% CI) by MyHEARTSMAP domain for the child and parent versions, respectively, were as follows: PSYCHIATRY PedsQL (r = 0.483±0.140 / 0.509±0.134) and SDQ (r = 0.417±0.150 / 0.598±0.116); FUNCTION PedsQL (r = 0.578±0.122 / 0.455±0.143); SOCIAL PedsQL (r = 0.249±0.170 / 0.158±0.175) and SDQ (r = 0.207±0.172 / 0.067±0.178).

Conclusion

In conclusion, MyHEARTSMAP PSYCHIATRY and FUNCTION domains have moderate convergent validity to PedsQL and SDQ. Unlike PedsQL and SDQ, the evaluation of social issues in MyHEARTSMAP is MH-specific, resulting in low convergent validity for the SOCIAL domain.
75 Paediatric Cannabinoid Hyperemesis Syndrome in the Emergency Department: a 5-year Retrospective Review
Authors: Foster Daniel , Van Aarsen Kristine , Yan Justin , Teefy John , Lynch Tim
Published: August 2020

Background

Cannabinoid Hyperemesis Syndrome (CHS) in paediatric patients is poorly characterized. Identification and treatment of adolescents presenting to the emergency department (ED) for suspected CHS is challenging. Given the paucity of literature on paediatric CHS and the recent legalization of cannabis, it is important to gain a better understanding of this disorder.

Objectives

The objective of this study was to describe demographics and ED visit data of paediatric patients presenting to the ED with suspected CHS.

Design/Methods

A retrospective chart review was conducted of paediatric patients (12-17 years) with suspected CHS presenting to one of two tertiary-care EDs; one paediatric (annual census 38,500) and one paediatric and adult (annual census 60,000) between April 2014-March 2019. Charts were selected based on discharge diagnosis of abdominal pain or nausea/vomiting with positive cannabis urine screen, or discharge diagnosis of cannabis use, using ICD-10 codes. Patients with confirmed or likely diagnosis of CHS were identified and data including demographics, clinical history, and ED investigations/treatments were recorded by a trained research assistant.

Results

A total of 242 patients met criteria for review. Thirty-nine were identified as having a confirmed or likely diagnosis of CHS (mean age 16.2, SD 0.85 years with 64% female), 87% were triaged as either CTAS-2 or CTAS-3 and 80% of patients had cannabis use frequency/duration documented. Of these, 89% reported at least daily use, the mean consumption was 1.30g/day (SD 1.13g/day), and all reported ≥6 months of heavy use. Sixty-nine percent of patients had at least one psychiatric comorbidity. When presenting to the ED, all had vomiting, 81% had nausea, 81% had abdominal pain and 30% reported weight loss. Investigations done included venous blood gas (30%), pregnancy test in females (84%), liver enzymes (57%), pelvic or abdominal ultrasound (19%), abdominal X-ray (19%), and CT head (5%). Eighty-nine percent of patients received treatment in the ED with 81% receiving anti-emetics, 68% receiving intravenous fluids, and 22% receiving analgesics. Normal saline was the most used intravenous fluid (80%) and ondansetron was the most used anti-emetic (90%). Cannabis was suspected to account for symptoms in 74% (with 31% of these given the formal diagnosis of CHS). Sixty-two percent of patients had another visit to the ED within 30 days (59% of these for similar symptoms).

Conclusion

This study of paediatric CHS reveals unique findings including a preponderance of female patients, a majority that consume cannabis daily, and weight loss reported in nearly 1/3rd. Many received extensive workups and most had multiple clustered visits to the ED.
81 Retropharyngeal and Parapharyngeal Infections in Children
Authors: Ratnapalan Savithiri , Thevaranjan Jeffrey , Diallo Mamadou
Published: August 2020

Background

Retropharyngeal and parapharyngeal infections are uncommon but life-threatening deep neck space bacterial infections that need prompt diagnosis and treatment for good outcomes. The retropharyngeal space contains chains of lymph nodes in young children, that atrophy and involute usually by four to five years of age. As these retropharyngeal nodes drain the nasopharynx, adenoids, posterior paranasal sinuses, and middle ear, they can get infected and suppurate following upper respiratory infections. The retropharyngeal space communicates laterally with the parapharyngeal space.

Objectives

To describe the presentations, diagnosis and management of retropharyngeal and parapharyngeal infections in children presenting to a tertiary care pediatric emergency department.

Design/Methods

A retrospective analysis of all patients diagnosed with retropharyngeal and parapharyngeal infections from 2008 to 2018 was performed. Data on demographic information, presenting symptoms, management and outcomes were extracted and analysed.

Results

200 children were identified with retropharyngeal or parapharyngeal abscess during the study period. The median age was 4.04 years (2.54, 5.62): 6.50% were under 1 year of age and 5.50% were between 10-16 years of age. Fever was present in 98.5 % (197) of children, 50% had feeding issues and 36.5% (73) had neck swelling at presentation. CT scans were performed in 74% (147) of children. There were 167 retropharyngeal infections, 19 parapharyngeal infections and 4 patients had both retropharyngeal and parapharyngeal infections. All patients were admitted and treated with parenteral antibiotics, the most common being intravenous Clindamycin (in 134), followed by a combination of Ceftriaxone and Clindamycin (in 44). One third of them (66) underwent surgical drainage.

Conclusion

About 12 % of retropharyngeal and parapharyngeal infections can occur in infants under a year of age or in adolescents. Most paediatric patients with retropharyngeal and parapharyngeal abscesses can be treated non-operatively with parenteral antibiotics and do not require surgery.
84 Impact of young age on outcomes of emergency department procedural sedation
Authors: Schlegelmilch Michael , Bhatt Maala , Roback Mark
Published: August 2020

Background

Procedural sedation in the emergency department (ED) for children undergoing painful procedures is common practice, however little is known about sedation in very young children.

Objectives

We examined the effect of young age on emergency department sedation outcomes.

Design/Methods

This is a secondary analysis of an observational cohort study of children 0-18 years undergoing procedural sedation in six pediatric EDs across Canada. We compared presedation state, indication for sedation, medications, sedation efficacy and four main post-sedation outcomes (serious adverse events (SAE), significant interventions, oxygen desaturation and vomiting) between patients who ≤ 2 years with those > 2 years. Pre-sedation state, medications, indication for sedation and time intervals were summarized using frequency and percentage and compared with chi2 test. Logistic regression was used to examine associations between age group and outcomes.

Results

6295 patients were included: 5349 (85%) were > 2 years and 946 (15%) were ≤ 2 years. Children ≤2 years were sedated most commonly for laceration repair (n=450; 47.6%), orthopedic reduction (165; 17.4%) and abscess incision and drainage (136; 14.4%). Children >2years were sedated most commonly for orthopedic reductions (3983; 74.5%). Ketamine was the most common medication in both groups, but was used most frequently in children ≤ 2 years (80.9% vs 58.9%; p<0.001). There was no difference in the incidence of SAE, significant interventions or oxygen desaturation between age groups, however, children ≤ 2 years were less likely to vomit (Table 1). Young children had decreased odds of a successful sedation (OR 0.48; 95%CI: 0.37 to 0.63). On average, patients ≤ 2 years were sedated for 7 minutes less (74.1 vs 81.0 p<0.001) and discharged 10 minutes sooner (90.1 vs 100.8 p<0.001).

Conclusion

Children ≤ 2 years most commonly received ED sedation for laceration repair using ketamine. Young age was not associated with a significant difference in SAEs, significant intervention or desaturation but was associated with decreased odds of vomiting and of successful sedation.
85 Parent and youth experiences of emergency department care for suspected long bone fractures in children
Authors: Gaucher Nathalie , Trottier Evelyne D , Ridha Zainab , Simard Francois , Duran Brenda , Pinard Celine , Larose Guylaine , D’Arsenault Michael , Angelo Antonio , Janvier Annie
Published: August 2020

Background

Long bone fractures are a frequent reason for visits to the pediatric emergency department (ED) where patients obtain the definitive care they require. Youth are rarely involved in quality assessment and improvement initiatives.

Objectives

To describe parent and youth experiences of their ED care for suspected long bone fractures.

Design/Methods

This prospective survey study of parents/youth consulting a tertiary care pediatric ED used surveys co-constructed by ED clinicians and parent partners. English/French speaking patients aged 10 to 18 years old with suspected long-bone fracture at triage – and their parents – were eligible to complete the survey during their ED stay. Electronic surveys were developed for parents and youth and pre-tested with 12 youth and 14 parents. Descriptive data was generated using SPSS v.25 (IBM Inc.).

Results

Three hundred surveys were distributed to eligible participants from March 2018 to June 2019 and 249 surveys were completed (148 parents, 101 youth). At least one member from 189 families completed a survey. Parents and youth participants had median ages of 44 and 12 years old, respectively. Most patients (98%) had a radiograph as part of their work-up, usually in the ED (76%); Twenty-seven percent were referred with radiographs. Most families (61%) received a diagnosis of long-bone fracture and were referred to orthopaedics for outpatient follow-up. Families’ median length of stay was 4h08min (range 43 min-14h30min). Parents (88mm) and youth (81mm) reported high median satisfaction with their overall ED care on 100 mm visual analog scales. Most parents (81%) and youth (75%) reported receiving just enough information from ED staff, though only half (50%) of the parents received information on how to care for their child at home. More than 90% of parents believed that the ED team treated their child’s pain. Eighty-one percent of youth reported that pain was treated sufficiently although 63% believed it had been treated quickly. Most parents (56%) and youth (72%) reported their ED stay was longer than anticipated; parents’ perceptions did not correlate with ED length of stay on logistic regression (p=0.014), while youth’s did (p=0.009). Few parents (33%) or youth (32%) reported receiving regular information on ED wait times.

Conclusion

Parent and youth perspectives of their ED care are complementary, and both should be considered in patient-oriented quality improvement initiatives.
89 Validation of the Severe Illness Getting Noticed Sooner (SIGNS) for Kids Tool in Children with Severe Illness
Authors: Gray Seth , Middaugh Kristen , Marsot-Shiffman Leah , He Calvin , Tremblay Ciara , Parshuram Christopher
Published: August 2020

Background

Severe illness in children is associated with significant risk of permanent disability, cardiac arrest, and death. The Severe Illness Getting Noticed Sooner (SIGNS) for Kids was created by an expert panel to help parents and other caregivers identify and articulate signs of severe illness to enable timely escalation of care. SIGNS for Kids consists of 5 major items: Behaviour, Breathing, Skin, Fluids, and Response to usually effective treatments. Expert development ensured face validity, however there is no formal validity evidence to suggest the tool can identify children with severe illness.

Objectives

To provide preliminary validity evidence of the sensitivity of the SIGNS criteria as markers of severe illness.

Design/Methods

A retrospective review of paediatric deaths was performed using records from the coroner’s office. Eligible patients had an index event described and were <18 years and >36 weeks gestational age at the time of event, had observations/reports for > 6 hours prior to the index event, and were not in an intensive care unit (ICU) or under anaesthetist supervision. The index events were defined as cardiac arrest, respiratory arrest, intubation, transfer to ICU, interfacility transfer, or urgent surgical procedure. Traumatic events and infants with sudden unexplained death were excluded from analysis. The main outcome was the presence of SIGNS items. Secondary measures were the time before index events that each of the SIGNS were present, and the time to death from the index event. Analyses were descriptive.

Results

Two hundred records were screened. After exclusion of 145 cases with incomplete records or traumatic deaths and 5 infants with sudden unexplained death, the records of 50 children met inclusion criteria. One or more SIGNS criteria were present before index event in 48 (96%). Breathing abnormality n=26 (52%) was the most frequently observed item with a mean (SD) duration of 47 (51) hours prior to index event. Over half (n=28, 56%) had SIGNS documented for ≥24 hours before initial escalation and 42 (84%) died within 48 hours after index event.

Conclusion

Forty-eight of 50 children had SIGNS criteria present before index event, and half had SIGNS present >24 hours. These data provide evidence of the sensitivity of the SIGNS criteria as markers of severe illness. Future studies will focus on establishing specificity and construct validity as well as caregiver usability prior to implementation of the screening tool.
97 Electrocardiographic features at rest and during exercise in young adults born preterm below 30 weeks of gestation
Authors: Gervais Anne-Sophie , Flahault Adrien , Tevy Chan , Bastien-Tardif Camille , Al-Simaani Amy , Cloutier Anik , Thuy Mai Luu , Sylvia Abadir , Anne-Monique Nuyt
Published: August 2020

Introduction/Background

Preterm birth has adverse consequences on the cardiovascular system. Whether premature birth is associated with conduction and repolarisation abnormalities past childhood and into adulthood still needs to be demonstrated. An exercise test could reveal such abnormalities.

Objectives

We aimed to assess electrocardiographic changes, particularly corrected QT (QTc) prolongation, in a cohort of young adults born preterm, at rest and during exercise.

Design/Methods

We analysed the ECG of young adults (23.9±3.1 years) born term (≥37 weeks, n=53) and preterm (<30 weeks, n=49) at rest, peak exercise and 3 minutes into recovery during an exercise test on a cycle ergometer. We measured PR, QRS and QT intervals, calculated the QTc, and determined blood calcium, magnesium, potassium and fasting glucose.

Results

Mean gestational age was 39.7±1.1 and 27.3±1.3 weeks for the term and the preterm groups, respectively. Apart from an increased heart rate at rest in individuals born preterm, no significant difference was found between both groups for any other ECG parameters at rest (Table 1). None of the participants had a severely prolonged QTc (>500ms) at rest; exercise revealed severely prolonged QTc in two participants including one in the preterm group. The use of QT-prolonging medications did not influence ECG parameters in either groups.

Conclusion

We observed no significant difference in electrocardiographic measurements between young adults born preterm and term. Current results do not support avoidance of QT-prolonging medications in individuals born preterm.
112 Becoming parents again: the challenges of raising grandchildren as main caregiver
Authors: Martin Ashley , Albrechtsons Daniel , Aumeerally Nadia , Wong Tania
Published: August 2020

Background

‘Skipped generation households’ in which grandparents are the main caregiver to children under 18 years of age, are becoming common in Canada. Reasons for this include teen pregnancy, the death of a parent, mental illness and addictions. These grandparents and the grandchildren they care for are at significantly increased risk of physical and mental illness, yet receive less psychosocial and financial assistance compared to children that enter the foster system. Research on this population in Canada is limited.

Objectives

Our study aimed to use the lived experiences of skipped generation families to better identify their needs in the healthcare system.

Design/Methods

We conducted semi-structured interviews of grandparent primary caregivers from ten households in our community to chronicle their lived experiences raising their grandchildren. Participants were identified and recruited by general pediatricians using convenience sampling. Interviews were recorded, transcribed verbatim, coded using Atlas.ti software and classified into themes by consensus.

Results

A total of 11 primary caregiver grandparents from 10 households participated in interviews. Nine participants were female. The average age of grandparents was 56 years (range 45 to 64 years) and on average they had been caring for their grandchild for 4 years (range 0.9 to 9 years). Eight households began caring for their grandchild following involvement of the Department of Community Services.

Five primary themes emerged from the interviews: Changes in family dynamics, psychosocial impact on grandchild and grandparent, lack of resources for grandparent caregivers, challenges parenting later in life, and resilience inspired by the love of family. Many participants described feeling unsupported, both financially and emotionally, after assuming care of their grandchildren and identified a need for additional counselling services, childcare subsidies and assistance through respite care. All participants involved highlighted that caring for their grandchildren changed their lives in many positive ways.

Conclusion

While grandparents are frequently prioritized as caregivers of apprehended children, our study suggests that they are also disproportionately under-resourced and poorly supported relative to children that instead enter the foster care system. Based on these findings, we urge for the provision of critical resources to address the emotional, respite and financial needs of these vulnerable children and their grandparents.
114 Distributional Decomposition: A Novel Method for Understanding Inequities in Child Growth, Behavior and Development
Authors: Fuller Anne , Siddiqi Arjumand , Shahidi Faraz , Anderson Laura , Keown-Stoneman Charles , Maguire Jonathon , Birken Catherine
Published: August 2020

Background

Income related inequities in child health are well-established, with children from lower income households showing increased risk of obesity, behavior problems, and delayed development. To facilitate clinical diagnosis, outcomes are conventionally measured in dichotomous terms. However, inequities may exist along the entire range of distribution, with implications for population health.

Objectives

Our primary objective was to examine differences in the distribution of three measures of child health by income: body mass index (BMI), behavior difficulties and development.

Design/Methods

This was a cross sectional study of children enrolled in a primary care practice-based research cohort. Our study included generally healthy children recruited from age 0-5 years. Dependent variables were 1) BMI z-score (zBMI) at 5 years; 2) behavior: total score on the Strengths and Difficulties Questionnaire (SDQ), measured at 3-5 years; 3) development: total score on the Infant Toddler Checklist (ITC), measured at 18-24 months. Independent variable was parent-reported annual household income (< $100,000 vs ≥ $100000). We then used distributional decomposition, which uses mathematical re-weighting to construct a counterfactual distribution that describes the distribution of the lower income group based on the predictor profile (child age, sex, birthweight, prematurity, breastfeeding duration; maternal age, education, immigration status, ethnicity) of the higher income group.

Results

Our study samples consisted of 1649 (zBMI), 764 (SDQ) and 761 (ITC) children. Mean BMI z-score was 0.16, median total difficulties score was 7, median ITC score was 48. Comparing distributions graphically (Figure 1), children with low income have a higher risk distribution for all outcomes; for example, children with low income were more likely to have BMI z-scores in the underweight and obese ranges. For each outcome, the counterfactual curve lower income children with the predictor profile of their higher income counterparts reduced inequities somewhat, particularly in the normal or low risk range, but not in the high-risk range. However, there were notable unexplained portions of inequity remaining.

Conclusion

In a cohort of generally healthy children, we found evidence of meaningful income-related inequities in the distribution of child zBMI, behavior difficulties, and development. Population health interventions aiming to mitigate these inequities by addressing common predictors may improve outcomes in the normal range; however targeted clinical interventions are likely required for those in the high-risk range.
116 Association between family income, risk for food insecurity and iron deficiency in healthy young Canadian children
Authors: Bayoumi Imaan , Parkin Patricia C , Birken Catherine S , Maguire Jonathon L , Borkhoff Cornelia M
Published: August 2020

Background

Iron deficiency peaks in prevalence (12% or higher) in early childhood and has been associated with poor developmental outcomes. Previous research examining associations between income and food insecurity (FI) with iron deficiency has been inconsistent and most did not measure iron status directly using serum ferritin or control for potential confounding variables.

Objectives

To examine the independent effects of family income and family risk for FI on iron status in healthy young children attending primary care.

Design/Methods

Healthy children ages 12–29 months were included in a cross-sectional analysis. Family income and risk for FI were collected from parents through self-reported questionnaires. Children with an affirmative response to the 1-item FI screen on the NutriSTEP (a validated screening tool of nutritional risk) or to at least one of the 2 items on the 2-item FI screen based on the 18-item Household Food Security Survey were categorized as a family at risk for FI. Iron status was assessed by serum ferritin. Children with C-reactive protein (CRP) >5 mg/L were excluded. Multivariable logistic regression analyses were used to examine the associations between both family income and family risk for FI with iron deficiency (serum ferritin <12µg/L) and IDA (serum ferritin <12 µg/L and hemoglobin <110 g/L), adjusting for age, sex, birthweight, zBMI, CRP, breastfeeding duration, bottle use, cow’s milk intake, formula feeding in the first year.

Results

Of 1245 children included, 131 (10.5%) of children were from households with a family income of <$40,000, 77 (6.2%) children were from families at risk for FI, 15% had iron deficiency, and 5% had IDA. The odds of children with a family income of <$40,000 having iron deficiency was 3 times (95% CI: 1.75, 5.26; P<0.0001) and having IDA was 4 times (95% CI: 1.71, 9.25; P=0.001) that for children in the highest family income group. Fully adjusted logistic regression showed weak evidence of a decreased odds of iron deficiency among children in families at risk for FI (OR 0.44, 95% CI: 0.19, 1.04; P=0.06) than all other children, and no association with IDA (OR 0.18, 95% CI: 0.02, 1.38; P=0.10).

Conclusion

A low family income of <$40,000 was associated with an increased risk for iron deficiency and IDA in young children. Risk for FI was not a risk factor for iron deficiency or IDA. Targeting income security may be more effective than targeting access to food to reduce health inequities in iron deficiency.
COVID-19 and chronic renal disease: clinical characteristics and prognosis
Authors: Yang D , Xiao Y , Chen J , Chen Y , Luo P , Liu Q , Yang C , Xiong M , Zhang Y , Liu X , Chen H , Deng A , Huang K , Cheng B , Peng A
Published: August 2020

Background

Patients on dialysis were susceptible to coronavirus disease 2019 (COVID-19) and were prone to severe clinical characteristics after infection; acute kidney injury was related to mortality in COVID-19 cases. Limited is known about the characteristics of COVID-19 patients with end-stage renal disease not requiring renal replacement therapy (RRT).

Aim

Evaluate clinical characteristics, course and outcomes of COVID-19 patients with chronic kidney disease (CKD) who did not require RRT and those on dialysis.

Design

A two-center retrospective study.

Methods

A total of 836 adult patients with COVID-19 (24 CKD not on dialysis; 15 dialysis-dependent CKD) were included. The study includes no patients with renal transplantation. Risk factors were explored.

Results

CKD not requiring RRT is an independent risk factor for in-hospital death [adjusted odds ratio (aOR) 7.35 (95% CI 2.41–22.44)] and poor prognosis [aOR 3.01 (95% CI 1.23–7.33)]. Compared with COVID-19 cases without CKD, those with CKD not requiring RRT showed similar percentage of initial moderate cases (75.00% vs. 73.65%) but higher incidence of in-hospital neutrophilia (50.00% vs. 27.30%) or death (50.00% vs. 9.03%). The odds ratio of dialysis associated to mortality in CKD patients was 2.00 (95% CI 0.52–7.63), suggesting COVID-19 patients with dialysis-dependent CKD were at greater risk of in-hospital death. For COVID-19 patients with CKD not requiring RRT, statins reduced the risk of neutrophilia [OR 0.10 (95% CI 0.01–0.69)] while diuretics increased the risk of neutrophilia [OR 15.4 (95% CI 1.47–160.97)], although both showed no association to mortality.

Conclusion

COVID-19 patients with CKD presented high incidence of neutrophilia, poor prognosis and in-hospital death, with dialysis patients being more vulnerable.
Proprotein convertase subtilisin/kexin type 9 in the dyslipidaemia of patients with axial spondyloarthritis is related to disease activity
Authors: de Armas-Rillo Laura , Quevedo-Abeledo Juan C , de Vera-González Antonia , González-Delgado Alejandra , García-Dopico José A , Jimenez-Sosa Alejandro , Rodríguez-Lozano Carlos , González-Gay Miguel A , Ferraz-Amaro Iván
Published: August 2020

Objective

Proprotein convertase subtilisin/kexin type 9 (PCSK9) is a serine protease that regulates cholesterol metabolism and has been linked to cardiovascular (CV) risk. The purpose of the present study was to examine whether PCSK9 levels are related to abnormalities in the lipid profile and the development of atherosclerosis that occurs in patients with axial SpA (axSpA).

Methods

We performed a cross-sectional study that encompassed 545 individuals; 299 patients with axSpA and 246 statin use–matched controls. PCSK9 and standard lipid profiles were analysed in patients and controls. Carotid intima-media thickness (cIMT) and carotid plaques were assessed in patients. A multivariable analysis, adjusted for standard CV risk factors, was performed to evaluate the influence of PCSK9 on axSpA-related dyslipidaemia and subclinical carotid atherosclerosis.

Results

Total cholesterol, high-density lipoprotein and low density lipoprotein cholesterol, lipoprotein (a) and apolipoprotein A1 were significantly lower in axSpA patients than controls. PCSK9 serum levels [β coefficient −44 ng/dl (95% CI −60, −27), P = 0.000] were also downregulated in axSpA patients after fully multivariable adjustment. ASDAS-CRP was found to be independently and significantly related to PCSK9 [β coefficient 10 ng/dl (95% CI 1, 18), P = 0.023] after analysing fully adjusted models that took age, sex and the rest of the lipid profile molecules into account. Whereas patients taking prednisone showed higher serum levels of PCSK9 [55 ng/ml (95% CI 24, 8), P = 0.001], those under anti-TNF-α therapies exhibited lower levels [β coefficient −26 ng/ml (95% CI −43, −9], P = 0.003].

Conclusion

PCSK9 is downregulated in patients with axSpA. Disease activity is positive and significantly related to PSCK9. Anti-TNF-therapy yields a reduction in PCSK9 serum levels.
Largest scale dissociation of brain activity at propofol-induced loss of consciousness
Authors: Pujol Jesus , Blanco-Hinojo Laura , Gallart Lluís , Moltó Luís , Martínez-Vilavella Gerard , Vilà Esther , Pacreu Susana , Adalid Irina , Deus Joan , Pérez-Sola Víctor , Fernández-Candil Juan
Published: August 2020

The brain is a functional unit made up of multilevel connected elements showing a pattern of synchronized activity that varies in different states. The wake–sleep cycle is a major variation of brain functional condition that is ultimately regulated by subcortical arousal- and sleep-promoting cell groups. We analyzed the evolution of functional MRI (fMRI) signal in the whole cortex and in a deep region including most sleep- and wake-regulating subcortical nuclei at loss of consciousness induced by the hypnotic agent propofol. Optimal data were obtained in 21 of the 30 healthy participants examined. A dynamic analysis of fMRI time courses on a time-scale of seconds was conducted to characterize consciousness transition, and functional connectivity maps were generated to detail the anatomy of structures showing different dynamics. Inside the magnet, loss of consciousness was marked by the participants ceasing to move their hands. We observed activity synchronization after loss of consciousness within both the cerebral cortex and subcortical structures. However, the evolution of fMRI signal was dissociated, showing a transient reduction of global cortico-subcortical coupling that was restored during the unconscious state. An exception to cortico-subcortical decoupling was a brain network related to self-awareness (i.e. the default mode network) that remained connected to subcortical brain structures. Propofol-induced unconsciousness is thus characterized by an initial, transitory dissociated synchronization at the largest scale of brain activity. Such cortico-subcortical decoupling and subsequent recoupling may allow the brain to detach from waking activity and reorganize into a functionally distinct state.
Identifying and managing bronchiolitis
Authors: Paluch Lauren
Published: August 2020

Bronchiolitis is a common viral illness that affects the lower respiratory tract of infants and young children. The disease is characterized by wheezing and increased mucus production and can range from mild to severe in terms of respiratory distress. This article reviews the epidemiology, clinical presentation, and treatment of bronchiolitis.
Infectious disease considerations in immunocompromised patients
Authors: McGrath Bridget , Broadhurst Mary , Roman Christopher
Published: August 2020

Immunocompromised patients account for about 3% of the US population. Complications arising from infection are common in these patients and can present diagnostic and therapeutic challenges. This article describes the pathophysiology of immunosuppression in five common immunocompromised states—asplenia, HIV infection, solid organ transplant, biologic use, and cancer—as well as specific infectious risks and considerations for affected patients and how to manage them.
Emerging practices in onboarding programs for PAs
Authors: Sanchez Mara , Anglin Lorraine , Rana Rachel , Butterfield Rita , Everett Christine M. , Morgan Perri
Published: August 2020

Objective:

Healthcare organizations are interested in creating onboarding programs to assist new PA and NP employees as they transition to practice settings. There is a need for information on what the ideal content and topic areas are for clinics to include in their onboarding programs.

Methods:

In 2018, we interviewed 13 administrators of onboarding programs. Interviews were transcribed and analyzed for themes by a team of researchers, with feedback from interviewees.

Results:

Eight content areas were identified and described in this paper: culture and values; goals and strategies; task proficiency; rules and policies; structure; working relationships; wellness; and navigation and politics.

Conclusions:

These common content areas may provide a starting point for organizations designing onboarding programs for their unique organizations.
Managing insomnia in older adults
Authors: Hedges Christine , Gotelli John
Published: August 2020

Nurses frequently care for patients with complaints of insomnia in the hospital and community settings. Because older adults with insomnia present unique challenges for successful patient management, nurses should understand the latest assessment and treatment options.
The vaping epidemic
Authors: Huey Sally , Tierney Catherine , Granitto Margaret , Brien Lori
Published: August 2020

Youth e-cigarette use was declared a national epidemic in 2018. This article discusses e-cigarette- or vaping-associated lung injury (EVALI) and highlights the unique role nurses can have as advocates, patient educators, and champions of health promotion and disease prevention for their patients and families.
Competitive Interactions between Halothane and Isoflurane at the Carotid Body and TASK Channels
Authors: Pandit Jaideep J. , Huskens Nicky , O’Donohoe Peadar B. , Turner Philip J. , Buckler Keith J.
Published: August 2020

Background

The degree to which different volatile anesthetics depress carotid body hypoxic response relates to their ability to activate TASK potassium channels. Most commonly, volatile anesthetic pairs act additively at their molecular targets. We examined whether this applied to carotid body TASK channels.

Methods

We studied halothane and isoflurane effects on hypoxia-evoked rise in intracellular calcium (Ca2
+
i, using the indicator Indo-1) in isolated neonatal rat glomus cells, and TASK single-channel activity (patch clamping) in native glomus cells and HEK293 cell line cells transiently expressing TASK-1.

Results

Halothane (5%) depressed glomus cell Ca2+
i hypoxic response (mean ± SD, 94 ± 4% depression; P < 0.001 vs. control). Isoflurane (5%) had a less pronounced effect (53 ± 10% depression; P < 0.001 vs. halothane). A mix of 3% isoflurane/1.5% halothane depressed cell Ca2+
i response (51 ± 17% depression) to a lesser degree than 1.5% halothane alone (79 ± 15%; P = 0.001), but similar to 3% isoflurane alone (44 ± 22%; P = 0.224), indicating subadditivity. Halothane and isoflurane increased glomus cell TASK-1/TASK-3 activity, but mixes had a lesser effect than that seen with halothane alone: 4% halothane/4% isoflurane yielded channel open probabilities 127 ± 55% above control, versus 226 ± 12% for 4% halothane alone (P = 0.009). Finally, in HEK293 cell line cells, progressively adding isoflurane (1.5 to 5%) to halothane (2.5%) reduced TASK-1 channel activity from 120 ± 38% above control, to 88 ± 48% (P = 0.034).

Conclusions

In all three experimental models, the effects of isoflurane and halothane combinations were quantitatively consistent with the modeling of weak and strong agonists competing at a common receptor on the TASK channel.

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What This Article Tells Us That Is New
The Pathophysiology, Diagnosis, and Management of Wolff–Parkinson–White Syndrome in the Neonate
Authors: Chambers Stephanie , Jnah Amy , Newberry Desi
Published: August 2020

Background:

Wolff–Parkinson–White (WPW) is a congenital defect of the cardiac conduction system (CCS), with proliferation of extra embryologic conduction pathways and rapid conduction of electrical impulses. The estimated neonatal incidence of 0.1% to 0.2% may be misrepresented secondary to missed or misdiagnosis. Undiagnosed WPW can result in sudden cardiac death.

Purpose:

To discuss the pathogenesis, manifestations, diagnosis, management, and lifespan implications of WPW in the prenatal and postnatal periods.

Methods/Search Strategy:

A literature review was conducted using PubMed, CINAHL, and Google Scholar (2013-2019). Search terms included (newborn OR infant), wolff parkinson white, pathogenesis, management, and ventricular preexcitation. After removal of duplicates, 267 references were identified, abstracts reviewed, and 30 publications fully evaluated.

Findings/Results:

Separation of the heart chambers begins around 7 weeks' gestation with formation of the annulus fibrosis complete after term. The unknown external environmental influence on the development of the preterm infant's CCS places neonates at risk for persistent atrioventricular reentrant tachycardia with WPW development. Ensuring an appropriate diagnosis is crucial, as an incorrect diagnosis could mean death.

Implications for Practice:

Due to the rarity of WPW, any fetal or neonatal supraventricular tachycardia requires further evaluation with an electrocardiogram and involvement of an experienced cardiologist for diagnosis. One episode of supraventricular tachycardia warrants evaluation for WPW, as recurring episodes may result in irreversible damage.

Implications for Research:

The recommendations for treatment of WPW in the prenatal and immediate postnatal periods are based heavily on standards of care for the adult population. A paucity of evidenced-based literature exists and future research is crucial to understand the true incidence, physiologic effects, and lifespan implications of WPW on neonates.
Medical Education and Safety as Co-priorities in the Coronavirus Disease 2019 (COVID-19) Era
Authors: Baecher-Lind Laura , Fleming Angela C. , Bhargava Rashmi , Cox Susan M. , Everett Elise N. , Graziano Scott C. , Katz Nadine T. , Sims Shireen Madani , Morgan Helen K. , Morosky Christopher M. , Sonn Tammy S. , Sutton Jill M. , Royce Celeste S. ,   for the Association of Professors of Gynecology and Obstetrics Undergraduate Medical Education Committee
Published: August 2020

As hospitals and medical schools confronted coronavirus disease 2019 (COVID-19), medical students were essentially restricted from all clinical work in an effort to prioritize their safety and the safety of others. One downstream effect of this decision was that students were designated as nonessential, in contrast to other members of health care teams. As we acclimate to our new clinical environment and medical students return to the frontlines of health care, we advocate for medical students to be reconsidered as physicians-in-training who bring valuable skills to patient care and to maintain their status as valued team members despite surges in COVID-19 or future pandemics. In addition to the contributions students provide to medical teams, they also serve to benefit from the formative experiences of caring for patients during a pandemic rather than being relegated to the sidelines. In this commentary, we discuss factors that led to students' being excluded from this pandemic despite being required at the bedside during prior U.S. public health crises this past century, and we review educational principles that support maintaining students in clinical environments during this and future pandemics.
Sepsis and Coronavirus Disease 2019: Common Features and Anti-Inflammatory Therapeutic Approaches
Authors: Beltrán-García Jesús , Osca-Verdegal Rebeca , Pallardó Federico V. , Ferreres José , Rodríguez María , Mulet Sandra , Ferrando-Sánchez Carolina , Carbonell Nieves , García-Giménez José Luis
Published: August 2020

Great efforts are being made worldwide to identify the specific clinical characteristics of infected critically ill patients that mediate the associated pathogenesis, including vascular dysfunction, thrombosis, dysregulated inflammation, and respiratory complications. Recently, coronavirus disease 2019 has been closely related to sepsis, which suggests that most deaths in ICUs in infected patients are produced by viral sepsis. Understanding the physiopathology of the disease that lead to sepsis after severe acute respiratory syndrome coronavirus 2 infection is a current clinical need to improve intensive care–applied therapies applied to critically ill patients. Although the whole representative data characterizing the immune and inflammatory status in coronavirus disease 2019 patients are not completely known, it is clear that hyperinflammation and coagulopathy contribute to disease severity. Here, we present some common features shared by severe coronavirus disease 2019 patients and sepsis and describe proposed anti-inflammatory therapies for coronavirus disease 2019 which have been previously evaluated in sepsis.