bluuebunny/crossref_metadata_2025 huggingface dataset:
Predictors and Management of Loss of Response to Vedolizumab in Inflammatory Bowel Disease
Authors: Shmidt Eugenia , Kochhar Gursimran , Hartke Justin , Chilukuri Prianka , Meserve Joseph , Chaudrey Khadija , Koliani-Pace Jenna L , Hirten Robert , Faleck David , Barocas Morris , Luo Michelle , Lasch Karen , Boland Brigid S , Singh Siddharth , Vande Casteele Niels , Sagi Sashidhar Varma , Fischer Monika , Chang Shannon , Bohm Matthew , Lukin Dana , Sultan Keith , Swaminath Arun , Hudesman David , Gupta Nitin , Kane Sunanda , Loftus Edward V , Sandborn William J , Siegel Corey A , Sands Bruce E , Colombel Jean-Frederic , Shen Bo , Dulai Parambir S
Published: May 2018

Background

We quantified loss of response (LOR) to vedolizumab (VDZ) in clinical practice and assessed the effectiveness of VDZ dose intensification for managing LOR.

Methods

Retrospective review (May 2014–December 2016) of a prospectively maintained inflammatory bowel disease (IBD) registry. Kaplan-Meier estimates were used to determine rates of LOR to VDZ . Independent predictors of LOR were identified using univariate and multivariable Cox proportional hazard regression. Success of recapturing response (>50% reduction in symptoms from baseline) and remission (complete resolution of symptoms) after dose intensification was quantified.

Results

Cumulative rates for VDZ LOR were 20% at 6 months and 35% at 12 months, with slightly lower rates in Crohn’s disease than in ulcerative colitis (6 months 15% vs 18% and 12 months 30% vs 39%, P = 0.03). On multivariable analysis, LOR to a tumor necrosis factor (TNF) antagonist before VDZ use was associated with an increased risk for LOR to VDZ [hazard ratio (HR) 1.93; 95% confidence interval (CI) 1.25–2.97] in all patients. For Crohn’s disease patients specifically, higher baseline C-reactive protein concentration was associated with increased risk for LOR to VDZ (HR 1.01 per mg/dL increase, 95% CI 1.01–1.02). Shortening of VDZ infusion interval from 8 to every 4 or 6 weeks recaptured response in 49% and remission in 18% of patients.

Conclusions

LOR to a TNF antagonist before VDZ use and higher baseline C-reactive protein are important predictors of VDZ LOR. Treatment response can be recaptured in almost half of these patients with VDZ infusion interval shortening.
The origin of interstellar asteroidal objects like 1I/2017 U1 ‘Oumuamua
Authors: Portegies Zwart Simon , Torres Santiago , Pelupessy Inti , Bédorf Jeroen , Cai Maxwell X
Published: May 2018

We study the origin of the interstellar object 1I/2017 U1 ‘Oumuamua by juxtaposing estimates based on the observations with simulations. We speculate that objects like ‘Oumuamua are formed in the debris disc as left over from the star and planet formation process, and subsequently liberated. The liberation process is mediated either by interaction with other stars in the parental star cluster, by resonant interactions within the planetesimal disc or by the relatively sudden mass loss when the host star becomes a compact object. Integrating ‘Oumuamua  backward in time in the Galactic potential together with stars from the Gaia-TGAS catalogue we find that about 1.3 Myr ago ‘Oumuamua  passed the nearby star HIP 17288 within a mean distance of 1.3 pc. By comparing nearby observed L-dwarfs with simulations of the Galaxy, we conclude that the kinematics of ‘Oumuamua is consistent with relatively young objects of 1.1–1.7 Gyr. We just met ‘Oumuamua  by chance, and with a derived mean Galactic density of ∼3 × 105 similarly sized objects within 100 au from the Sun or ∼1014 per cubic parsec we expect about 2–12 such visitors per year within 1 au from the Sun.
Trends and Cost-Analysis of Lower Extremity Nerve Injury Using the National Inpatient Sample
Authors: Foster Chase H , Karsy Michael , Jensen Michael R , Guan Jian , Eli Ilyas , Mahan Mark A
Published: May 2018

BACKGROUND

Peripheral nerve injuries (PNIs) of the lower extremities have been assessed in small cohort studies; however, the actual incidence, national trends, comorbidities, and cost of care in lower extremity PNI are not defined. Lack of sufficient data limits discussion on national policies, payors, and other aspects fundamental to the delivery of care in the US.

OBJECTIVE

To establish estimates of lower extremity PNIs incidence, associated diagnoses, and cost in the US using a comprehensive database with a minimum of a decade of data.

METHODS

The National Inpatient Sample was utilized to evaluate International Classification of Disease codes for specific lower extremity PNIs (9560–9568) between 2001 and 2013.

RESULTS

Lower extremity PNIs occurred with a mean incidence of 13.3 cases per million population annually, which declined minimally from 2001 to 2013. The mean ± SEM age was 41.6 ± 0.1 yr; 61.1% of patients were males. Most were admitted via the emergency department (56.0%). PNIs occurred to the sciatic (16.6%), femoral (10.7%), tibial (6.0%), peroneal (33.4%), multiple nerves (1.3%), and other (32.0%). Associated diagnoses included lower extremity fracture (13.4%), complications of care (11.2%), open wounds (10.3%), crush injury (9.7%), and other (7.2%). Associated procedures included tibial fixation (23.3%), closure of skin (20.1%), debridement of open fractures (15.4%), fixation of other bones (13.5%), and wound debridement (14.5%). The mean annual unadjusted compounded growth rate of charges was 8.8%. The mean ± SEM annual charge over the time period was $64 031.20 ± $421.10, which was associated with the number of procedure codes (β = 0.2), length of stay (β = 0.6), and year (β = 0.1) in a multivariable analysis (P = .0001).

CONCLUSION

These data describe associations in the treatment of lower extremity PNIs, which are important for considering national policies, costs, research and the delivery of care.
A Comparison of Cefazolin Versus Ceftriaxone for the Treatment of Methicillin-Susceptible Staphylococcus aureus Bacteremia in a Tertiary Care VA Medical Center
Authors: Carr Dustin R , Stiefel Usha , Bonomo Robert A , Burant Christopher J , Sims Sharanie V
Published: May 2018

Background

Cefazolin and ceftriaxone are frequently used to treat methicillin-susceptible Staphylococcus aureus (MSSA) bacteremia, especially in the realm of outpatient parenteral antimicrobial therapy. Both antimicrobials have been associated with favorable clinical outcomes for mixed MSSA infections. However, limited published data exist specifically comparing the use of these agents for the treatment of MSSA bacteremia.

Methods

We conducted a retrospective cohort study of Veteran patients with MSSA bacteremia who received ≥14 days of cefazolin or ceftriaxone between 2009 and 2014. Rates of treatment failure were compared between both groups. Treatment failure was defined as therapy extension, incomplete therapy, unplanned oral suppressive therapy, relapse of infection, or hospital admission or surgery within 90 days.

Results

Out of 71 patients, 38 received treatment with cefazolin and 33 with ceftriaxone. The overall rate of treatment failure was 40.8%, with significantly more failures among patients receiving ceftriaxone (54.5% versus 28.9%; P = .029). Factors associated with treatment failure included longer duration of parenteral therapy, heart failure, and treatment in an external skilled nursing facility as compared with treatment in the Department of Veterans Affairs attached Community Living Center.

Conclusions

Ceftriaxone had a higher rate of treatment failure than cefazolin for the treatment of MSSA bacteremia in a Veteran population. Potential reasons for this could include the higher protein binding of ceftriaxone, ultimately resulting in lower serum concentrations of free drug, or other unknown factors. Further studies are warranted to confirm these results.
LES INTOXICATIONS SÉVÈRES À L’ALCOOL CHEZ LES JEUNES
Authors: Cyr Claude
Published: May 2018

BACKGROUND

Chez les adolescents, une visite à l’urgence reliée à l’alcool est un facteur prédictif important de problèmes continus de consommation.

OBJECTIVES

Décrire le type de présentation, les caractéristiques cliniques et la prise en charge des jeunes intoxiqués à l’alcool admis aux urgences.

DESIGN/METHODS

Étude rétrospective descriptive des jeunes (12 à 24 ans) admis aux urgences du Centre Hospitalier Universitaire de Sherbrooke (CHUS) en raison d’une intoxication à l’alcool entre janvier 2012 et janvier 2017.

RESULTS

Sur un total de 855 admissions, 56% étaient des garçons. Un hospitalisation de plus de 24 heures a été nécessaire pour 77 jeunes (9%) et 44 ont nécessité une ventilation méchanique (5%). L’âge moyen était de 19,7 ans, 167 (20%) avait entre 12 et 17 ans. Le taux d’éthanolémie moyen était de 208.8 mg/dl, 55 (6) avec des taux de plus de 300 mg/dl. Une altération de l’état de conscience a été documentée dans 68% des cas avec 23% des patients présentant une menace potentielle pour la vie. Des pics de consultation étaient présents aux semaines 35 (rentrée universitaire) et 44 (Halloween). L’utilisation d’alcool fort a été identifié dans 74% des cas. Seulement 29% avait consommé une autre substance psychotrope. La co-intoxication la plus fréquente étant le cannabis (n=119,14%). Des complications ont été identifié dans 57% des admissions dont 195 (23%) traumatismes, 85 (10%) bagarres, 22 (3%) blessures auto-infligées, 10 (1%) abus sexuelles. Seulement 52% des patients ont reçu un councelling lors de leur séjour à l’urgence.

CONCLUSION

Les intoxications aigues à l’alcool chez les jeunes sont fréquentes et sévères. Ce projet permettra de dégager des pistes préventives au sein de la communauté sherbrookoise.
PRISE EN CHARGE MULTIDISCIPLINAIRE D’ADOLESCENTS AVEC SYMPTÔMES DOULOUREUX FONCTIONNELS RÉFRACTAIRES
Authors: Proulx-Cabana Stephanie , Picard Louis , Fortin Marie-Claude , Couillard Jo-Anne , Taddeo Danielle , Jamoulle Olivier , Frappier Jean-Yves , Stheneur Chantal
Published: May 2018

BACKGROUND

La douleur chronique, d’origine organique ou somatique, représente un fardeau financier important au niveau du système de santé. L’intervention multidisciplinaire a été démontrée efficace pour améliorer cliniquement l’impact fonctionnel de cette condition.

OBJECTIVES

Étude de l’impact d’une prise en charge multidisciplinaire pédiatrique et psychologique sur les symptômes douloureux fonctionnels et leur retentissement dans une population adolescente référée pour échec de prise en charge nitiale.

DESIGN/METHODS

Analyse rétrospective de dossiers d’adolescents, de 14 à 18 ans, suivis en clinique des adolescents pour des symptômes douloureux fonctionnels entre janvier 2016 et juin 2017. L’équipe multidisciplinaire est composée de pédiatre, psychologue en suivi individuel ou lors du groupe d’intervention en gestion de la douleur, physiothérapeute et infirmière.

RESULTS

24/36 adolescents ayant des symptômes réfractaires avaient des dossiers exploitables. L’âge médian était de 15,9 ans [14,9; 16,3] avec 87,5% de filles dans l’échantillon. Les principales plaintes rapportées étaient des céphalées (50%), nausées/vomissements (50%), douleurs abdominales (37,5%), douleurs musculo-squelettiques (37,5%), fatigue (37,5%) et symptômes neurologiques (20,8%). Le nombre médian de plaintes étaient de 2 par patient. À la consultation initiale, pour le symptôme principal, la durée médiane écoulée depuis l’apparition était de 13 mois [3,75; 34,5], l’intensité médiane de 6/10 et la fréquence médiane de 7 jours/semaine. Le nombre médian de consultations médicales avant la prise en charge spécialisée était de 3 [2; 5], dont 76,6% d’entre elles en surspécialité pédiatrique. Les patients avaient un nombre médian d’intervenants psychosociaux impliqués au dossier initial de 1, dont un psychologue dans 42,4%. Initialement, 83,3% des patients présentaient un absentéisme scolaire significatif. Suite à la prise en charge, nous avions une amélioration des symptômes pour 70,8% et de l’absentéisme scolaire pour 63,6%. Les symptômes de nausées/vomissements étaient les plus persistants. Sur notre petit groupe d’adolescents, il n’a pas été possible de mettre en évidence de différence significative entre ceux qui avaient bénéficié du groupe d’intervention et les autres.

CONCLUSION

Dans une population d’adolescents avec symptômes douloureux fonctionnels dont la prise en charge en première ligne n’a pas été efficace, une prise en charge multidisciplinaire spécialisée permet une amélioration des symptômes et de la fréquentation scolaire dans 2/3 des cas.
PAEDIATRIC PROJECT ECHO: EXPLORING THE EDUCATIONAL NEEDS OF ONTARIO HEALTHCARE PROVIDERS WITH INTEREST IN CARING FOR CHILDREN WITH MEDICAL COMPLEXITY
Authors: Marcinko Josip , Orkin Julia , Cohen Eyal , Ho Michelle , Lalloo Chitra , Jiwan Annie , McKillop Adam , Kulandaivelu Yalinie , Stinson Jennifer
Published: May 2018

BACKGROUND

Project ECHO® is an innovative, interactive model for medical education and healthcare delivery that expands access and capacity to provide evidence-informed care. This model virtually connects specialist interprofessional teams with community healthcare providers (HCPs). It aims to increase knowledge, build capacity, and ultimately, improve patient outcomes by bringing expertise to the community. This project focuses on the first paediatric implementation of Project ECHO for children with medical complexity. This is the first Project ECHO for this population.

OBJECTIVES

In preparation for this novel program launch in January 2018, a needs assessment was conducted with the objectives of: (1) informing the complex care-specific ECHO curriculum; and (2) assessing community partner preferences for program format and delivery modality.

DESIGN/METHODS

An online survey (38 items; 15-minutes) was distributed via targeted emails to professional networks, associations, and allied health organizations related to complex care throughout Ontario. The survey assessed interest in specific educational topics as well as program format preferences. An online survey and data management tool (REDCap) was used to build the survey and ensure data quality and security.

RESULTS

49 HCPs completed the survey for Paediatric Project ECHO for Children with Medical Complexity. Profession breakdown was: 29% paediatricians, 19% dieticians, 16% nurses, 14% nurse practitioners with the remaining being allied health care professionals, including occupational therapists, social workers and psychologists. Overall, 39% of participants practiced in academic hospitals, 27% in non-academic hospitals, and 35% in other community settings. In terms of program format, 63% preferred weekly 1- or 2-hour educational sessions versus longer sessions. Top medical topics rated by HCPs were: management of nutrition, pain or irritability of unknown origin, and challenging behaviours in children with complex care needs. Other topics of interest included: developmental review, transition to adult care, advanced care planning, funding opportunities, and social supports for the patient as well as caregivers and siblings.

CONCLUSION

HCPs who expressed interest in Paediatric Project ECHO for Children with Medical Complexity are generally experienced professionals who preferred short educational sessions. The themes that emerged from this needs assessment spanned the biological, psychological and social domains of management of complex care patients. Survey results are being used to inform the development of an evidence-based paediatric complex care curriculum that meets the needs of community HCPs.

This project is funded by the MOHLTC.
DOES BREASTFEEDING DURATION INFLUENCE FAMILY FOOD INSECURITY?
Authors: Wong Peter , Moodie Rosemary , Dai David , Maguire Jonathon , Birken Catherine , Parkin Patricia , Borkhoff Cory
Published: May 2018

BACKGROUND

Across all demographics, families without consistent access to adequate food place children at health risk. Consequences may persist beyond early life into adulthood. Public policy positions breastfeeding, the ideal nutrition for infants, as an important solution to reducing family food insecurity (FFI). However, few studies have investigated the association between breastfeeding duration and FFI.

OBJECTIVES

To evaluate the association between total breastfeeding duration and FFI in Canadian urban children.

DESIGN/METHODS

A cross-sectional study was conducted of children aged 0–2 years, from a practice-based child research network. Total breastfeeding duration was collected from parent-reported questionnaires. FFI was measured using 2-item food insecurity and validated 1-item NutriSTEP screens. Multivariable regression analysis was performed adjusting for pre-specified covariates.

RESULTS

Among 3838 children, the mean total breastfeeding duration was 10.6 months (SD=6.7). Families with food insecurity (14.7%) had increased odds of younger mothers, more males and older and more children. In adjusted model, breastfeeding duration was not associated with FFI (OR 0.99; 95% CI 0.98, 1.01). Low-income families were 9 times more likely to be family food insecure than high-income families (p=0.00).

CONCLUSION

Contrary to public policy, our study found no association between breastfeeding and family food insecurity (FFI). However, other factors may predominate, in particular family income and structure. Given the detrimental impact of FFI, further research is needed to understand the role of infant feeding practices within the larger political, policy and cultural framework.
DEFINING PEDIATRIC DIABETES USING EMR RECORDS AND VALIDATION FROM LINKABLE MANITOBA COHORT DATA
Authors: Singer Alexander , Kosowan Leanne , Queenan John , Yeung Roseanne , Amed Shazhan , Wicklow Brandy
Published: May 2018

BACKGROUND

The prevalence of paediatric diabetes is increasing. Identifying and describing populations with paediatric diabetes using Primary Care Electronic Medication Records (EMR) can improve surveillance and management.

OBJECTIVES

To describe the population of children diagnosed with paediatric diabetes in Manitoba using Electronic Medical Record data from Community Paediatricians and Family Physcians in Manitoba.

DESIGN/METHODS

We applied a previously validated case definition for type 1 and type 2 diabetes to patients aged 1–18 seen by one of the 221 primary care providers participating in the Manitoba Primary Care Research Network (MaPCReN) between 1998–2015. We compared the agreement between the MaPCReN definition and Manitoba’s Diabetes Education Resource for Children and Adolescents (DERCA) clinical database of confirmed cases. Cases were described, including prevalence, patient characteristics, and health system use.

RESULTS

Our definition identified 166 children (0.4%, 95% CI 0.36% - 0.49%) of whom 53.0% lived in a rural location and 53.6% were female. The mean age at diagnosis was 11.4 years (SD 5.4). There were 90 patients identified by the definition also cared for by a paediatric endocrinologist at DERCA [sensitivity (54.2%), specificity (98.7%), and kappa (0.61, CI 0.54-.069)]. An additional 286 patients had at least one documented HbA1C of 6.5% or higher but did not have a corresponding diabetes diagnosis within the EMR. Of those, 45% had an HbA1c between 6.5 -7.5 and 25.9% had an HbA1c over 8.5%. Most of these patients also had an abnormal fasting glucose in the EMR (76.9%). There were 280 patients with an elevated HbA1c that had no evidence of attending an appointment with a paediatric endocrinologist at DERCA, 70.8% have a rural address.

CONCLUSION

The inclusion of HbA1c values in identifying paediatric diabetes suggested a large number of patients without a corresponding diabetes diagnosis or record of care from DERCA. Therefore, the DERCA database might be underestimating the true prevalence of diabetes in Manitoba. Understanding further characteristics of this population, is an essential step to inform the development of enhanced services and strategies.
‘MILK VOLUME, MILK FAT AND CHILDHOOD FRACTURE RISK
Authors: Allison Riley , Maguire Jonathon
Published: May 2018

BACKGROUND

Children who do not consume cow’s milk have been associated with an increased risk of fracture. Cow’s milk is consumed by most North American children yet the relationships between the volume of cow’s milk consumed, the fat content of cow’s milk and childhood fracture risk are unclear.

OBJECTIVES

The primary objective was to evaluate whether volume of cow’s milk consumed between ages 1 - 3 was associated with fracture between ages 3 - 10. Secondary objectives explored whether milk-fat consumed between ages 1 - 3 was associated with fracture between ages 3 - 10 and whether milk-fat content modified the relationship between milk volume and fracture.

DESIGN/METHODS

This was a prospective analysis of 2466 healthy urban children with exposure between 1 and 3 years of age and outcome between 3 and 10 years of age enrolled in the TARGet Kids! -Applied Research Group for Kids cohort. The primary exposure was the volume of cow’s milk consumed and the secondary exposure was the average percentage of milk-fat consumed by each child. The outcome was one or more fractures experienced, measured as yes or no. A modified Poisson regression was used to evaluate the relationship between volume of cow’s milk at exposure, and one or more fractures at outcome. The same analysis was used to explore the relationship between cow’s milk-fat and fracture. Effect modification by milk-fat consumed on the relationship between milk volume and fracture risk was explored by adding an interaction term to the statistical model.

RESULTS

In the primary adjusted analysis, a statistically significant association between the volume of cow’s milk consumed at exposure and risk of one or more fractures at outcome was not observed (aRR= 1.04; 95% CI: 0.87 to 1.26). In the secondary analysis, a statistically significant association between cow’s milk-fat consumed at exposure and fracture risk at outcome was also not observed (aRR= 1.05; 95% CI: 0.84 to 1.31). Cow’s milk-fat did not modify the relationship between milk volume and risk of fracture. (p= 0.24).

CONCLUSION

In this prospective cohort study of young children, we did not identify a protective effect of early childhood volume of cow’s milk or milk-fat consumption on fracture risk in later childhood. Future research in young children is needed to evaluate specific low impact fracture mechanisms, which may be more sensitive to nutritional factors.
KINDERGARTEN-AGE NEUROCOGNITIVE AND FUNCTIONAL OUTCOMES AFTER LIVER TRANSPLANTATION DONE AT AGE <6 YEARS
Authors: Wong Kerry , Joffe Ari R , Yap Jason , Acton Bryan , Dinu Irina , Moez Elham Khodayari , Robertson Charlene MT
Published: May 2018

BACKGROUND

Mortality after liver transplant has improved, making long-term outcomes increasingly important.

OBJECTIVES

To describe neurocognitive and functional outcomes after liver transplant done in young children, and determine potentially modifiable risk factors for adverse outcomes.

DESIGN/METHODS

Between 1999–2014, all <6 years old liver transplant recipients at our center were enrolled in this ethics board approved, longitudinal inception-cohort. Demographic, pre-transplant, transplant, and post-transplant data were prospectively collected. Following informed consent, outcomes were determined by experienced paediatric psychologists using Wechsler Preschool and Primary Scale of Intelligence III, Beery-Buktenica Developmental Test of Visual-Motor Integration-V (VMI), and Adaptive Behavior Assessment System-II. Associations with outcomes (Full-Scale intelligence quotient [FSIQ], Performance IQ [PIQ], Verbal IQ [VIQ], VMI and General Adaptive Composite [GAC]) were determined using multiple linear regression. Population norms for each score are mean 100 (SD15).

RESULTS

78 liver transplants were performed; 69 patients survived, and all completed follow-up. Outcomes for the 60 patients without metabolic disease are reported. FSIQ, PIQ, and VIQ were 94.5 (17.0), 95.4 (17.8), and 93.7 (17.6). VMI and GAC were 91.6 (16.2) and 89.7 (18.0). Outcomes were shifted to the left of population norms, with the proportion having IQ scores >1 SD (score <85, expected 15.9%) and >2 SD (score <70, expected 2.27%) below population norms being: 23.3% and 8.3%, 25% and 8.3%, and 21.7% and 11.7% respectively. For VMI and GAC these proportions were 25% and 8.3%, and 35% and 13.3%. There were few predictors of outcomes: for FSIQ, grade-IV encephalopathy [effect size -15, 95%CI -29,-1; p=0.03]; PIQ, grade-IV encephalopathy [effect size -16, 95%CI -31, -1; p=0.04], VIQ, grade-IV encephalopathy [effect size -17, 95%CI -31, -4; p=0.01], living-related donor [effect size 10, 95%CI 2, 18; p=0.02], and rejection in first 30d [effect size 9, 95%CI 0.5, 17; p=0.04]; and VMI, grade-IV encephalopathy [effect size -20, 95%CI -33, -7; p=0.002], and PELD at activation [effect size 0.5, 95%CI 0.2, 0.9; p=0.006]. Variables not associated with neurocognitive outcomes included: age at transplant, year of transplant, having any severe complication post-operatively, growth failure, and socioeconomic status.

CONCLUSION

Neurocognitive and functional outcomes after liver transplant at age <6 years are shifted to the left of population norms. Severe encephalopathy at transplant predicted a poorer outcome. More research is needed to determine risk factors for the over 3X higher prevalence of scores <70 compared to population norms.
THE USEFULNESS OF DEAMIDATED GLIADIN PEPTIDE IN SCREENING PEDIATRIC PATIENTS FOR CELIAC DISEASE
Authors: Gould Michelle , Brill Herbert , Marcon Margaret , Walsh Catharine
Published: May 2018

BACKGROUND

Celiac disease (CD) is an autoimmune enteropathy triggered by gliadin. The gold standard for diagnosis is small bowel biopsy. Screening with serologic markers to identify endoscopic candidates is commonly completed by paediatricians. The most common serologic marker used for screening is IgA anti-Tissue Transglutaminase (TTG) antibodies. Antibodies to deamidated gliadin peptide (DGP) is a newer assay with studies demonstrating a diagnostic performance similar to anti-TTG. In Canada, this assay has been added to many laboratory’s celiac screening panels. There is little evidence however regarding the usefulness of an isolated positive anti-DGP result in paediatric patients and no study has systematically assessed the presence of biopsy proven CD in solely anti-DGP positive paediatric patients.

OBJECTIVES

We sought to determine the positive predictive value of anti-DGP for biopsy proven CD in paediatric patients with negative TTG IgA testing.

DESIGN/METHODS

A multi-center retrospective review of children referred to three centers in Ontario, Canada between January 2015 and December 2016 who had isolated anti-IgG DGP positive CD serology was completed. To be included, patients required serology positive for DGP IgG and negative for all other celiac serologic tests, as well as a duodenal biopsy while on a gluten-containing diet. The positive predictive value of isolated anti-DGP was calculated.

RESULTS

A total of 83 patients were identified with anti-DGP positive, anti-TTG negative serology. Of these, 40 patients underwent endoscopy. Only 1 patient had findings consistent with CD on biopsy (Marsh 3B histology), yielding a positive predictive value of 2.5%. This patient was IgA deficient. Amongst the cohort of IgA sufficient patients (N=25), the positive predictive value of anti-DGP serology was 0%. One additional patient who was IgA sufficient had findings in keeping with Marsh 2 histology, but repeat TTG and DGP testing was negative. Five patients were found to be IgA deficient at the time of serologic testing, 25 were IgA sufficient and 10 did not have a measured IgA.

CONCLUSION

Isolated positive DGP IgG serology has a poor positive predictive value for CD, especially in IgA sufficient individuals. For this reason, DGP IgG testing should not be completed as part of the initial screening for celiac disease in the paediatric population unless a compelling reason, such as IgA deficiency or age under 2 years, is present, in order to prevent unnecessary invasive follow-up testing and costs to patients and the health care system.
IMPACT OF A QUALITY IMPROVEMENT INITIATIVE ON UNPLANNED EXTUBATION (UE) RATE IN THE NEONATAL INTENSIVE CARE UNIT (NICU)
Authors: Hewitt Mark , Sproul Erin , Hudson Jo-Anna , Emberley Julie
Published: May 2018

BACKGROUND

Unplanned extubations (UEs) refer to any removal of an endotracheal tube not directly ordered or intended by the medical team. It is the fourth most common adverse event in the neonatal intensive care unit (NICU) and can lead to significant morbidity in this vulnerable population. A large proportion of UEs in the NICU are deemed preventable and UE rates are increasingly being recognized as an important quality of care metric.

OBJECTIVES

To examine the effectiveness of an education-based quality improvement initiative to decrease UE rate in a level II/III NICU with a high rate of UEs

DESIGN/METHODS

Pre-intervention UE rate was determined by retrospective chart review for all intubated neonates admitted to a 25 bed level II/III NICU from January 2013 until December 2013. UEs were recorded along with demographic information including reason for extubation.

UE rate was calculated by number of UEs/100 ventilator days and the data was analyzed to determine any significantly associated risk factors. The UE quality improvement initiative included: multi-disciplinary NICU staff education sessions, placement of educational posters in the NICU and identification of high risk neonates as defined by the pre-intervention study. High risk neonates were given additional signage to alert care providers. Standardized documentation was implemented to track and record UEs prospectively. Six months post-implementation, all UE events were reviewed from December 2015 until May 2016 and the post-intervention UE rate was calculated.

RESULTS

The UE rate was 3.28 UEs/100 ventilator days in the pre-intervention cohort with neonatal movement and adhesive failure accounting for over 50% of the documented UEs. Regression analysis revealed total ventilation time to be the only significant (p<0.05) risk factor for an UE. In the post-intervention cohort the UE rate was 1.45 UEs/100 ventilator days, a 56% decrease from the pre-intervention rate. Rates of re-intubation following an UE were 78.3% and 50% for the pre- and post-implementation cohorts respectively.

CONCLUSION

Reduction in UE rate from 3.28 to 1.45 was achieved with an education-based multi-disciplinary quality improvement initiative. Rates of re-intubation following an UE were similar between cohorts. Further study is necessary to evaluate whether the effectiveness of this intervention will persist over time and whether results are generalizable to other NICUs.
COST-EFFECTIVENESS OF PULSE OXIMETRY SCREENING FOR CRITICAL CONGENITAL HEART DEFECTS IN ONTARIO
Authors: Mukerji Amit , Shafey Amy , Jain Amish , Cohen Eyal , Shah Prakeshkumar , Shah Vibhuti , Sander Beate
Published: May 2018

BACKGROUND

Critical congenital heart defects (CCHDs) are a leading cause of morbidity and mortality in newborns, and late diagnosis is associated with mortality and worse outcomes. Many jurisdictions in the USA and elsewhere have implemented routine pulse oximetry screening (POS) for CCHD, which the Canadian Paediatric Society has recently endorsed. Cost-effective analyses in USA and Europe support this approach, but the geographical setting of Ontario in relation to its vast yet sparsely populated regions presents unique challenges with regard to POS implementation.

OBJECTIVES

To estimate the cost-effectiveness of POS for CCHD in the context of its implementation in Ontario, Canada.

DESIGN/METHODS

A cost-effectiveness analysis using a Markov model was conducted inputting values derived from an extensive review of literature, and using relevant local databases. The base-case was a 24-hour clinically stable infant born in Ontario. The model employed the healthcare payer (ministry of health) perspective and a life-time horizon. A number of mutually exclusive health states were created, representative of the natural course of CCHDs. The strategies compared were routine pulse oximetry screening versus no screening. Outcome measures, all discounted 1.5%, were quality-adjusted life months (QALMs), lifetime costs, and incremental cost-effectiveness ratios. An a priori threshold of CAD$4,166.67 per QALM (equivalent to CAD$50,000 per quality adjusted life year) was used. Probabilistic sensitivity analysis was conducted using multiple simulations of the model within expected range of variables included in the model.

RESULTS

The incremental cost of performing POS was estimated to be $27.27 per individual, with a gain of 0.02455 QALMs (Table 1). This yielded an incremental cost-effectiveness ratio (ICER), [Δ Cost / Δ QALMs] of CAD$1,110.79, well below the pre-determined threshold for cost-effectiveness. A probabilistic sensitivity analysis estimated a 93% chance of routine implementation of POS of being cost-effective, with majority of simulated ICERs lying below the threshold of acceptability (Figure 1).

CONCLUSION

Routine implementation of POS for CCHD is expected to be cost-effective with a high degree of certainty. Further validation of this model may be conducted following implementation to confirm these findings based on local population data.
ESTIMATING UMBILICAL VENOUS CATHETER INSERTION DEPTH IN NEWBORNS USING BIRTH WEIGHT OR BODY MEASUREMENT: A RANDOMIZED TRIAL
Authors: Sheta Ayman , Soraisham Amuchou , Kamaluddeen Majeeda
Published: May 2018

BACKGROUND

Incorrectly positioned Umbilical Venous Catheters (UVC) are associated with serious complication in newborns. Accurate prediction of insertion depth, as well as confirmation of position; are important factors to avoid complications. UVC position verification by standard radiography is imprecise in comparison to ultrasound. A retrospective study reported Surface Measurement (SM: umbilicus to nipple distance in cm minus 1) was more accurate than Shukla’s Birth Weight (BW) based formula [(3× birth weight (Kg) + 9)/2 + 1)] for estimating UVC insertion depth.

OBJECTIVES

The primary objective is to compare the proportion of optimum UVC position (verified by ultrasound) using SM / BW based insertion depths formulas.

Secondary objective is to compare the proportion of optimum UVC position between the two methods based on birth weight, and growth status of the infants.

DESIGN/METHODS

In this prospective randomized trial, infants undergoing UVC insertion were randomly assigned to either SM or BW based formula. Infants with hydrops, major congenital heart disease, abdominal wall defects, or congenital diaphragmatic hernia were excluded. The optimum UVC position was then verified using ultrasound in addition to the standard radiography.

The primary outcome was optimum UVC position determined by ultrasound, read by an investigator blinded to the assignment. Optimum UVC tip position was defined as the catheter tip in the inferior vena cava between the hepatic vein confluence and right atrial opening. Intention to treat analysis was performed.

RESULTS

Of the 196 enrolled infants, 97 were assigned to SM based and 99 to BW based formula. UVC insertion was successful in 195 infants, however the catheter could not be advanced to the targeted depth in 36 infants (18 in each group). There was no difference in baseline demographic parameters. There was no difference in the primary outcome between infants assigned to SM or BW based formula (35% vs 27%, Relative risk (RR), 1.28; 95% CI 0.84 -1.95). In the subgroup analysis for ELBW (<1000g); proportion of optimum UVC position was significantly higher with SM based as compared to BW based formula [14/32 (44%) vs 6/31 (19%), p = 0.03]. Similarly, for SGA (Small for Gestational Age)/LGA (Large for Gestational Age) infants, SM based formula showed better positioning than BW based formula [8/15 (53%) vs 4/16 (25%), p = 0.10].

CONCLUSION

Although no significant difference was noted in the percent of optimum UVC position using either SM or BW based formulas; SM based formula was superior in ELBW, SGA and LGA infants.
OUTCOME OF PRETERM INFANTS AFTER DELIVERY ROOM CARDIOPULMONARY RESUSCITATION. A RETROSPECTIVE OBSERVATIONAL STUDY
Authors: Gautam Bishal , McKnight Sarah , Miller Michael , Richardson Bryan , Ahmed Abrar , da Silva Orlando
Published: May 2018

BACKGROUND

Chest compression in the delivery room (CPR-DR) during neonatal resuscitation is considered as an extreme measure. When respiratory support alone is unable to establish circulatory transition, chest compression with or without epinephrine is necessary. The results of earlier studies have shown varied results in mortality and morbidity of preterm infants who received CPR-DR.

OBJECTIVES

To examine the relationship between need of CPR-DR in infants born between 23 and 32 weeks gestation and neonatal mortality and morbidity.

DESIGN/METHODS

This was a population-based cohort study of 23 0/7 to 32 6/7 weeks gestational age infants born at a Canadian tertiary care hospital between January 1, 2007 and December 31, 2016. Data were retrieved from the Neonatal-Perinatal database. Neonatal mortality and morbidities were examined between infants who did and did not need CPR-DR.

RESULTS

Of 1443 newborns meeting study criteria, 55 (3.8%) received CPR-DR. On bivariate analysis, outcome of infants requiring CPR-DR was associated with higher mortality (40% vs. 5.8%, p <0.001), intraventricular hemorrhage grade 3 or 4 (21.8% vs. 6.1%, p <0.001), patent ductus arteriosus (54.5% vs. 27.7%, p<0.001), bronchopulmonary dysplasia (35.4% vs. 19.6%, p=0.007), need of mechanical ventilation (90.9% vs. 61.1%, p<0.001) and sepsis (23.6% vs. 13.5%, p=0.034). However, in a multivariable logistic regression analysis controlling for predictor variables, CPR-DR was only associated with increased neonatal mortality (aOR=4.41 p<0.001, 95%CI [2.18, 8.92]).

CONCLUSION

While CPR-DR is associated with a high mortality rate in infants less than 32 weeks gestation, associated morbidities are largely predicted by other risk factors.
CARDIOVASCULAR DERANGEMENT IN NEONATAL HERPES INFECTION
Authors: Bhattacharya Soume , McNamara Patrick , Giesinger Regan
Published: May 2018

BACKGROUND

Disseminated Herpes Simplex infection is a severe neonatal illness with high mortality and morbidity. Despite acyclovir treatment, the fulminant disease may be rapidly progressive and treatment is largely supportive. A significant proportion of neonates with this illness require intensive care support for circulatory insufficiency and hypoxic respiratory failure. Extracorporeal membrane oxygenation may be used as rescue therapy, though mortality remains high. The pathophysiological contributors to the disease phenotype, the mechanisms underlying the hemodynamic instability and therapeutic strategies to treat such cardiovascular dysfunction have not been well described.

OBJECTIVES

To describe patterns of cardiovascular dysfunction using targeted neonatal echocardiography and response to therapy for neonates with disseminated herpes infection in a quaternary neonatal intensive care unit.

DESIGN/METHODS

A cohort of all neonates with confirmed disseminated herpes simplex virus (HSV) infection admitted over the period of November 2014- April 2017 were included in this study. All neonates were evaluated by comprehensive targeted neonatal echocardiography (TnECHO) assessment within the first 24h of admission. Demographic and clinical features were collected retrospectively from the electronic medical record. All TnECHO measurements were performed by a single expert operator. Ethical approval was obtained from the institutional ethics board.

RESULTS

Five neonates, 3 with HSV 1 and 2 with HSV 2, were identified during the study period. All had features of profound circulatory insufficiency such as hypotension, metabolic acidosis with high lactate, oliguria/anuria, poor capillary refill etc. Three neonates had severe oxygenation failure. On functional echocardiographic assessment, we found that all cases demonstrated underfilled cardiac chambers and low cardiac outputs suggesting severe vasodilatation and third space losses. These cases were managed by aggressive volume resuscitation and use of peripheral vasoconstrictors such as Vasopressin and Nor-Epinephrine. Primary ventricular dysfunction was identified in 3 neonates, who were treated with dobutamine and/or epinephrine. Significant pulmonary hypertension was detected in three infants which prompted the use of Inhaled Nitric Oxide. Acyclovir was initiated early on. Significant cardiovascular stabilization could be achieved by such targeted hemodynamic therapy. However, in view of extensive neurological and hepatic damage, life sustaining therapy was eventually withdrawn in all of them.

CONCLUSION

Cardiovascular dysfunction in neonates with disseminated HSV infection may be due to either primary ventricular dysfunction, vasodilatation and third space losses or due to pulmonary hypertension. Early targeted neonatal echocardiography may enhance physiologic definition and facilitate targeted therapy. Mortality from multisystem complications, however, remains universal, which raises the question of the role of ECMO in this population.
MODE OF DELIVERY AND ITS IMPACT ON NEONATAL OUTCOMES IN PRETERM INFANTS
Authors: McKnight Sarah , Gautam Bishal , Miller Michael , Richardson Bryan S , da Silva Orlando
Published: May 2018

BACKGROUND

The optimal mode of delivery for preterm infants remains controversial, and routine Caesarean sections (C/S) are not recommended, except for maternal indications. Nonetheless, many preterm infants are delivered by C/S, particularly those in breech presentation, and recent retrospective data have suggested that these infants may have improved outcomes.

OBJECTIVES

To examine whether C/S as the mode of preterm delivery is associated with decreased mortality and improved short term outcomes.

DESIGN/METHODS

This retrospective, population-based cohort study examined infants with a gestational age between 23 0/7 weeks and 32 6/7 weeks, born between January 1, 2007 and December 31, 2016, and admitted to the Neonatal Intensive Care Unit at a single Canadian Tertiary Care hospital. Infants with major congenital anomalies were excluded. Data were abstracted from the local Neonatal-Perinatal database for all infants. Two groups, those delivered vaginally and those delivered by C/S, were compared for major neonatal outcomes including the primary outcomes of death and severe intraventricular hemorrhage (IVH), defined as grade 3 or higher.

RESULTS

A total of 1442 infants met inclusion criteria (784 born by C/S and 658 vaginally). There was no significant difference in neonatal mortality (7.0% vs 7.1%, p=0.925) or severe IVH (6.1% vs 7.4%, p=0.317). There was, however, a significant difference in the incidence of IVH, any grade (19.9% vs 27.5%, p=0.001), which remained after controlling for other significant predictors. There were no other significant differences in the secondary outcomes examined including need for extensive resuscitation, respiratory distress syndrome, bronchopulmonary dysplasia, patent ductus arteriosus, necrotizing enterocolitis, periventricular leukomalacia, or retinopathy of prematurity.

CONCLUSION

Caesarean section was not associated with decreased mortality in preterm infants, relative to vaginal births. Caesarean section was associated with a reduced rate of IVH (any grade) and there was a trend towards decreased severe IVH which may warrant further study.
ASSESSMENT OF HEART RATE USING AUSCULTATION AND ELECTROCARDIOGRAPHY DURING NEONATAL RESUSCITATION IN A PORCINE MODEL OF ASPHYXIA
Authors: Patel Sparsh , Cheung Po-Yin , Lee Tze-Fun , Mustofa Jannatul , Pasquin Matteo , O’Reilly Megan , Schmolzer Georg
Published: May 2018

BACKGROUND

Recent neonatal resuscitation guidelines have suggested the potential benefit of introducing Electrocardiography (ECG) to monitor neonatal heart rate (HR) as standard of care for newborns receiving respiratory support in the delivery room due to advantages over auscultation.

OBJECTIVES

To assess effectiveness of HR detection using either ECG or auscultation.

DESIGN/METHODS

We reviewed recordings from our piglet neonatal resuscitations to compare an ECG with auscultation for assessing the detection of HR at cardiac arrest. Term newborn piglets (n=41) were anesthetized, intubated, instrumented, and exposed to 40-min normocapnic hypoxia followed by asphyxia, which was achieved by clamping the endotracheal tube until asystole. Asystole was confirmed by using Electrocardiography and auscultation.

RESULTS

The median (±IQR) duration of asphyxia was 318 (200–560)sec. In 41 piglets both auscultation and ECG HR were assessed. In 11 (27%) cases both auscultation and ECG correctly identified a bradycardic HR (mean (SD) 32(14)/min) at the beginning of chest compression. In 11 (27%) cases both auscultation and ECG correctly identified absent of any HR. However, in 19 (46%) cases auscultation did not detect a HR while ECG did detect a HR. Overall, the Positive Predictive Value was 37%, Negative Predictive Value was 100%, Sensitivity was 100%, and Specificity was 37% for the ECG to display accurate HR during asphyxia in newborn piglets.

CONCLUSION

Our data illustrates the need for caution in the routine use of ECG monitoring for all neonatal who might need advanced resuscitation in the deliver room.
IS IT A SURPRISE? SHOCKING SUB-OPTIMAL MEDICATION SAFETY IN CHILDREN WITH MEDICAL COMPLEXITY
Authors: Patel Hema , Bourassa Marie-Helene , Huth Kathleen , Vandecruys Patricia
Published: May 2018

BACKGROUND

There are increasing numbers of children with medical complexity (CMC) worldwide. CMC make multiple transitions between healthcare settings and providers; frequently receiving multiple medications. While the risk of medication error in children is recognized, data on CMC, perhaps one of the most vulnerable groups, is lacking.

OBJECTIVES

To explore parental knowledge, perceptions and behaviours around medication safety and to identify and describe recalled medication errors in order to guide future efforts in quality and safety.

DESIGN/METHODS

Study participants: Parents of CMC followed in a university hospital based specialized clinic. Study design: Cross-sectional prospective survey, administered by face-to-face interview.

Study methods: Because no pre-existing suitable validated survey tool was identified, a 35-item bilingual survey was developed using quantitative and qualitative methods. Testing for face and construct validity was conducted. Consecutive parents of CMC presenting to a designated clinic were approached for study participation. Following informed consent, parents were interviewed for 12–15 minutes with responses entered into a web-based secure database with integrated statistical analysis for data interpretation. Additional diagnostic, verification and healthcare utilization data were collected from the medical chart.

RESULTS

Complete data was collected for 51 CMC; 77% of respondents were mothers; 3 parents declined to participate. Children, 35% female, ranged in age between 6 months and 17 years. Polypharmacy was common; 77% of CMC had 3 or more medications, 53% had five or more daily medications. Only 37% of parents reported having a complete list of their child’s medications; less than quarter of those administering liquid medications were able to report the actual dose/concentration. Almost two-thirds of parents were worried that their child might have a medication error in the future with 45% recalling at least one medication error in the past. Of these parents, 76% reported that the error occurred during inpatient hospital stay, most commonly due to a dosage error. The reported impact on the child due to the error included life-threatening situations.

CONCLUSION

Medication error in CMC is perceived and reported as a significant risk by parents. Nonetheless, only a minority were able to show a list of their child’s medications. The rate of reported errors suggests that existing prevention practices remain suboptimal. Further study in other care settings is warranted to confirm these findings and to determine which strategies may be most effective in reducing the risk of medication error in CMC.