bluuebunny/crossref_metadata_2025 huggingface dataset:
The Fan Study: Intranasal Fentanyl and Inhaled Nitrous Oxide for Fracture Reduction
Authors: Hoeffe J , Trottier ED , Bailey B , Shellshear D , Lagacé M , Sutter C , Grimard G , Cook R , Babl FE
Published: September 2022

BACKGROUND: Recently, intranasal (IN) fentanyl and inhaled nitrous oxide/oxygen (N2O) mixture have been increasingly used for procedural sedation and analgesia (PSA) alone or in combination. There is a lack of data on the efficacy of these combined agents.

OBJECTIVES: To evaluate the efficacy of IN fentanyl and N2O as PSA for the reduction of mildly-to-moderately displaced fractures and dislocations.

DESIGN/METHODS: We performed a prospective, observational cohort study between September 2014 and October 2015. Patients were recruited at CHU Sainte Justine (Montréal, Canada) and Royal Children Hospital (Melbourne, Australia). Patients between the age of 4 and 18 years were eligible if PSA consisted of IN fentanyl and N2O for the reduction of mildly-to-moderately displaced fractures or dislocations. Patients received at least IN fentanyl 1.5 mcg/kg (100 mcg max) and at least a 50/50% mixture of N2O with oxygen. Primary outcome was the efficacy of PSA measured by the patient assigned Facial Pain Scale-Revised (FPS-R). The Face, Legs, Activity, Cry, Consolability (FLACC) scale was also recorded. Depth of sedation was evalu-ated using the University of Michigan Sedation Scale (UMSS). Adverse events were recorded following the criteria of the Consensus Panel on Sedation Research of PERC/PECARN. Additional data concerning satisfaction or discomfort were evaluated via questionnaires, and follow-up telephone calls were made to elicit information on adverse events after discharge.

RESULTS: A total of 91 patients aged 9.7±3.0 years were enrolled. There was no difference between the median FPS-R score during the procedure compared to before: Median 2 and 2 (median difference 0 [95% CI 0, 0]), respectively. The FLACC score was higher during the procedure than before: Median 4 and 0 (median difference 2 [95% CI 1, 3]). UMSS was 1 (95% CI 1, 2) during the procedure. 42 (46%) patients had adverse events, all mild: vertigo (20%), nausea (16%)]or vomiting (12%). A total of 85/88 (97%) parents and 82/85 (96%) ED physicians would want the same sedation in another procedure.

CONCLUSION: PSA with IN fentanyl and N2O seems effective in our cohort study, as evaluated by patient assigned FPS-R. Patients were minimally sedated. Adverse events were frequent but mild. Overall, parents and medical staff would want the same agents used in another procedure. Thus, PSA with IN fentanyl and N2O appears to be an attractive option for reduction of mildly displaced fractures or dislocations.
PrÉvalence Et DÉterminants De La Non-Vaccination Contre L’hÉpatite B Chez Les Adolescents Au Canada, 2013
Authors: Caron-Poulin L , Gilbert N , Wilson S , Gilmour H
Published: September 2022

HISTORIQUE: Le Comité consultatif national de l’immunisation (CCNI) recommande depuis 1993 la mise en place de programmes de vaccination universelle contre l’hépatite B au Canada. Depuis 1998, des programmes de vaccination universelle contre l’hépatite B sont place partout au pays. Les calendriers de vaccination systématique ne sont toutefois pas harmonisés.

OBJECTIFS: Mesurer la couverture vaccinale pour l’hépatite B rapportés et identifier les facteurs de risques associés à la non-vaccination.

MATÉRIALS/MÉTHODE: Nous avons analysé les données de 6805 adolescents de 17 ans inclus dans l’enquête nationale sur la couverture vaccinale des enfants (ENCVE) de 2013 pour identifier les facteurs socio-démographiques associés à la non-vaccination, c’est-à-dire n’avoir reçu aucune dose du vaccin contre l’hépatite B. Les variables indépendantes incluses dans l’analyse étaient les provinces et territoires, le fait que les adolescents ou les parents soient nés à l’extérieur du Canada ou non, le statut matrimonial des parents et le niveau d’éducation de ces derniers en plus du revenu familial moyen. Les rapports de cotes ont été calculés au moyen de regressions logistiques simples et multiples. Les intervalles de confiance ont été estimés par la méthode bootstrap.

RÉSULTATS: En tout, 87.9% des adolescents avaient reçu au moins une dose du vaccin. Il n’y avait pas d’association significative entre le statut socioéconomique et le statut vaccinal des enfants pour l’hépatite B. Il existe cependant des différences au niveau de couverture vaccinale pour ce vaccin entre les différentes provinces et territoires du Canada. De plus, à 17 ans le fait d’être né à l’extérieur du Canada était associé à un risque plus élevé d’être non-vacciné comparativement aux enfants nés au Canada, et ce à la limite du seuil de signification (p=0.556).

CONCLUSION: Il existe des différences entre les taux de couvertures des provinces et territoires malgré des programmes de vaccination systéma-tique contre l’hépatite B dans toutes les juridictions. Par contre, il ne semble pas y avoir d’inégalité socioéconomique en lien avec le statut vac-cinal de l’hépatite B des adolescents. Ceci est un fait encourageant pour les programmes de promotion en place dans le pays.
Comparison of First- and Second-Season Palivizumab Prophylaxis in Patients with Chronic Lung Disease (CLD) in the ‘Caress’ Database (2005-2014)
Authors: Paes B , Wang D , Li A , Mitchell I , Lanctot K
Published: September 2022

BACKGROUND: Respiratory syncytial virus (RSV) related hospitaliza-tion (RSVH) rates are 10-fold higher in infants with CLD compared with healthy term infants until 24 months of age. Current pediatric advisory guidelines recommend RSV prophylaxis for CLD infants < 2 years of age based on oxygen requirement for at least 28 days after birth during the first RSV season and those who continue to require chronic medical therapy for the management of CLD during the second season.

OBJECTIVES: This study compared RSVH rates in CLD infants who received palivizumab during the first RSV season (FS) versus the second season (SS) in the Canadian Registry of Palivizumab (CARESS) database.

DESIGN/METHODS: CARESS is a prospective registry of infants who received palivizumab at one of 32 sites across Canada during the 2005-2014 RSV seasons. Demographic data were collected at enrollment and respiratory-illness related hospitalization events were recorded monthly. Infants aged < 24 months with CLD were enrolled.

RESULTS: 797 (55%) and 647 (45%) of 1444 CLD infants were prophy-laxed during FS and SS respectively (average age: 6.9 [FS] versus 13.6 [SS] months). SS infants had a lower gestational age [29.7 versus 31.3 weeks, F(1, 1440) = 29.9, p=<0.0005] and birth weight [1447 versus 1762 grams, F(1, 1436) = 29.3, p=<0.0005]. Infants prophylaxed in the SS also experienced more complicated neonatal courses with: prolonged respiratory support [63.4 versus 50.0 days, F(1, 1089) = 16.9, p=<0.0005], oxygen therapy [135.7 versus 74.8 days, F(1, 1155) = 97.4, p=<0.0005], and longer hospital stays [102.0 versus 72.0 days, F(1, 1369) = 62.1, p=<0.0005]. RSVH rates were 2.23% (FS) and 2.66% (SS). Cox regression adjusted for daycare attendance, multiple births, gestational age, birth weight and neonatal complications found no significant differences in the time to first RSVH between FS and SS infants (Hazard ratio: 0.96, 95% CI 0.37–2.52, p=0.94).

CONCLUSION: SS infants who received RSV prophylaxis for CLD had a similar hazard of RSVH to those who only received palivizumab in the first year of life. The findings imply that FS and SS infants are correctly selected for RSV prophylaxis based on the stipulated criteria and their severity of illness and that SS infants are equally at risk for RSVH compared to FS infants.
Comparing First- and Second-Season Palivizumab Prophylaxis in Patients with Hemodynamically Significant Congenital Heart Disease (HSCHD) in the ‘Caress’ Database (2005-2014)
Authors: Paes B , Li A , Mitchell I , Lanctot K
Published: September 2022

BACKGROUND: Compared with normal children, RSV-related hospi-talization (RSVH) rates in children with HSCHD are 2-4 fold higher even up to 2 years of age with an overall weighted mean mortality rate of 5.2%. Pediatric advisory guidelines recommend prophylaxis against respiratory syncytial virus (RSV) for infants with HSCHD. However, current recommendations cast doubt as to whether prophylaxis is beneficial beyond 1 year of age.

OBJECTIVES: To determine whether there are differences in RSVH in HSCHD infants receiving palivizumab during the first versus second RSV season in the Canadian Registry of palivizumab (CARESS).

DESIGN/METHODS: CARESS is a prospective registry of infants who received ≥1 dose of palivizumab at one of 32 sites across Canada during the 2005-2014 RSV seasons. Demographic data were collected at enrollment and respiratory-illness-related hospitalization events recorded monthly. In the event of a hospitalization, the relevant hospital records were reviewed by the site’s research nurse for detailed information on criteria for hospital-ization, length of stay (regular ward vs. ICU), days on respiratory support and/or intubation, and RSV test type and diagnosis. Infants aged <24 months with cyanotic or acyanotic HSCHD were recruited.

RESULTS: 1306 (64.9%) of 2013 infants received prophylaxis only for the first season. 707 (35.1%) were prophylaxed during the second season (average age in months: 4.7 [first season] vs 14.7 [second season]). Baseline demographics for both seasons were similar. However, infants aged >1year had a more complicated neonatal course, with significantly longer neonatal length of stay (46.7 versus 25.6 days). Infants received: 4.5±1.4 injections; 90.5% of their expected injections and 88.2% of their injections within the appropriate time intervals. 26 infants in the first year (RSVH rate: 2.26%) and 11 infants in the second year (RSVH rate: 2.09%) were hospitalized. Cox regression analysis showed no significant differences in hazards between infants in their first or second year of prophylaxis in the time to first RSVH (Hazard ratio: 1.4, 95%CI 0.5-4.0, p=0.52)

CONCLUSION: Infants enrolled in the CARESS database in the second RSV season had a similar hazard of RSVH as those in the first year of life. These findings suggest that infants aged >1 year with HSCHD who remain unstable, are equally at risk for RSVH and merit palivizumab prophylaxis.
Development of a Paediatric Musculoskeletal Skills Workshop for Canadian Medical Students
Authors: Chan M , Rumsey D , Ellsworth J , Foster H
Published: September 2022

BACKGROUND: Musculoskeletal (MSK) complaints in children account for up to 30% of visits to general practitioners. Doctors who see children with MSK complaints are often not confident in assessing them and MSK exams are poorly documented in medical records. There has been little published literature describing the logistics of teaching MSK skills in a group setting (which is how medical students are commonly taught). At our center, no MSK examination skills were previously taught during the undergraduate paediatrics clerkship.

OBJECTIVES: 1) To develop a hands-on, paediatric MSK workshop for medical students with direct observation and feedback. 2) To evaluate student/faculty satisfaction with the workshop. 3) To develop an MSK workshop protocol as a resource for medical educators.

DESIGN/METHODS: A 1-hour interactive workshop was designed for students to practice the paediatric Gait, Arms, Legs and Spine (pGALS) screening MSK exam. Students are given pre-reading, videos and pGALS checklists. Workshops include live demonstrations and videos/images of abnormal MSK findings for pGALS practice. Students practice pGALS with their peers with staff supervision(up to 5 physicians present)and receive feedback. All students complete a post-workshop evaluation. Teachers also complete a post-workshop evaluation discussing what went well and areas for improvement.

RESULTS: Workshops are delivered every 2 months for 25 students (5 iterations completed). Feedback has been positive (median rating 4.5 on a 5-point Likert scale) for all areas evaluated: objectives, handouts, preparation time, discussion, resources, etc. Comments include: “Helpful and applicable to personal clinical practice,” and, “The hands-on practice was really appreciated, as was the chance to get feedback.” Workshops have been modified according to faculty/student evaluations, resulting in a workshop protocol (organizational template) for future workshop leaders including a teaching checklist, preparation timeline, and PowerPoint to be modified by instructors as they wish.

CONCLUSION: The paediatric MSK workshop has been a welcome addition to our undergraduate paediatrics clerkship curriculum. We aim to further develop our workshop by explicitly including applied anatomy, e.g., land-marking for joints. We also aim to make our workshop protocol available on Paediatric Musculoskeletal Matters,www.pmmonline.org, as a resource for other medical educators. Further work will include evaluating its uptake, use and applicability by users in different contexts, and modifying it for different levels of learners, e.g., paediatricians.
Serum Calcium Derangements in Neonates with Hypoxic Ischemic Encephalopathy (HIE) With and Without Therapeutic Hypothermia
Authors: Bashir R , Vayalthrikkovil S , Espinoza L , Mohammad K
Published: September 2022

BACKGROUND: Perinatal hypoxia is a recognized cause of hypocalcemia in neonates in the first 3 days of age. However, therapeutic hypothermia (TH), the standard care for moderate to severe HIE, promotes neuropro-tection by decreasing calcium (Ca) influx into the cells during reperfusion phase. So TH can increase serum Ca levels and may even negate the hypo-calcemic effects in HIE.

OBJECTIVES: To examine the trends in serum Ca levels in neonates with HIE with and without TH.

DESIGN/METHODS: A retrospective cohort study of neonates with moderate to severe HIE admitted to a level III NICU between September 2011 and October 2015. HIE staging was done as per modified Sarnat’s scoring system. Hypercalcemia was defined as serum ionised Ca (iCa) >1.35 mmol/L and hypocalcemia was defined as serum iCa <0.9 mmol/L. Acidosis was considered if pH <7.2. Serum Ca and pH were followed in the first 3 days of age (Day 1-3). The relation of serum Ca levels with acidosis,seizures, intracranial hemorrhage, and MRI changes in neonates with and without TH was examined. Categorical variables were analysed using chi-square test. Logistic regression analysis was done to explore the association of hypo/hypercalcemia with various variables, adjusting for TH, HIE staging, and acidosis.

RESULTS: Total number of neonates with moderate-severe HIE= 113; 89 neonates (79%) underwent TH. Incidence of hypercalcemia was 57/89 (88%) in the TH group whereas only one-third in the no TH group, whereas for hypocalcemia, it was 11/89(12%) and 5/24(21%) for the TH and no TH groups respectively. Hypercalcemia on Day 1 was significantly higher with TH(p 0.007) and acidosis(p 0.015). Hypocalcemia did not have any such association. Hypo/hypercarbia did not seem to alter the serum Ca levels. There was no increase in intracranial hemorrhage, clinical/EEG seizures, antiepileptic drug use or hypoxic MRI changes with Ca derangements.

CONCLUSION: Incidence of hypocalcemia was reduced by almost half in TH group. Hypercalcemia on day 1 was significantly associated with TH and acidosis. On days 2 and 3, hypercalcemia occurred in TH even in the absence of acidosis, but the association was not statistically significant. Less hypocalcemia and more hypercalcemia in TH may be attributed to the neuroprotective effect of TH by inhibiting Ca influx into the cells. However, there was no correlation between Ca derangements and seizures or severity of hypoxic changes in MRI.
Location! Location! Location! The Impact of Single-Room Design on Neurodevelopment of Preterm Infants
Authors: Church P , Ng E , Weisz D , Cavanagh A , Dunn M
Published: September 2022

BACKGROUND: The impact of neonatal intensive care unit (NICU) design on neurodevelopmental outcomes of preterm infants is uncertain. Although single room design (SRD) reduces nosocomial infections and improves breastfeeding rates and parental satisfaction, recent data suggests that SRD may be associated with language delays and alterations in cortical development.

OBJECTIVES: To compare neurodevelopmental outcomes of preterm infants who received care in a contemporary SRD environment compared with a similar cohort who received care during an earlier period with an open bay design (OBD).

DESIGN/METHODS: Retrospective single-centre cohort study comparing the neurodevelopmental outcomes of all surviving extremely low birth weight (ELBW) i nfants admitted within 24 hours of birth in 2009 (OBD epoch) and 2011 (SRD epoch). The primary outcome was moderate or severe neurodevelopmental impairment using the Bayley Scales of Infant Development, third edition (BSID-III) at 18 months corrected age. Secondary outcomes included severe NDI and BSID-III scores. Multivariable logistic regression (MLR) analysis was used to evaluate the independent association between NICU design and outcomes.

RESULTS: The study included 100 ELBW infants in 2009, and 98 in 2011. The 2 epochs were similar in follow-up rates (80% in 2009; 82% in 2011) and infant characteristics (including those lost to follow up). Mortality was 7.9% in 2009 and 6.1% in 2011. BSID-III language scores (median [interquartile range]) were similar for infants in the OBD and SRD epochs (86 [71,100] vs. 81 [71,94], p=NS). On MLR analysis, NICU design was not associated with significant differences in NDI or BSID-III language score less than 80 after adjustment for antenatal and perinatal confounders. (Table1)

CONCLUSION: There was no significant difference in NDI between cohorts of ELBW infants cared for in an SRD compared with an OBD NICU design environment. The contrast in findings from earlier studies may be attributable to the local context of government-supported parental leave and strong promotion of parental presence in the NICU.
Academic Challenges for the Preterm Infant: Parent and Educator Perspectives
Authors: Church P , Cavanagh A , Shah V
Published: September 2022

BACKGROUND: Preterm birth (PTB) is linked with academic challenges, attention deficit hyperactive disorder (ADHD) and behavioural problems. Emerging data suggest that educators lack awareness of the pre-term child's educational needs while no data exists regarding par-ents' understanding of these issues.

OBJECTIVES: To explore educators' and parents' level of knowledge of the impact of PTB on academic achievement, ADHD, and behavioural problems adn identify facilitators/barriers to the use of available educational resources.

DESIGN/METHODS: A combination of focus groups and survey were used to examine educators' and parents' knowledge, attitudes, and barriers to the impact of PTB on academic performance. Focus groups were conducted at the kindergarten to grade 3 levels at 4 schools by a trained facilitator using a guide. Parents of preterm infants who were seen in Neonatal Follow Up Clinic with children being 4 to 8 years of age participated. The survey included questions on parental perception of knowledge among their child’s educator of outcomes of PTB, current educational placement for their child and perception of barriers and facilitators. Data were analyzed using thematic analyses or descriptive statistics.

RESULTS: Educators with knowledge about PTB stated that it was largely experiential and none received formal training. Current training is focused on ADHD, Autism, or Fetal Alcohol Syndrome. In regard to facilitators/ barriers, there was no consensus on what resources would be useful (e.g. enrolling child based on the expected rather than actual date of birth if they fall in separate academic enrollment years or having knowledge that the child was preterm). Survey showed that most parents informed educators about their child’s history of PTB. This disclosure increased with decreasing gestational age (GA) (92.9% for <26 weeks, 85.5% for 27-32 weeks, and 54% for >33 weeks). 54% of parents believed that their child had learning challenges and attributed this to the child’s PTB. 40% believed that the school met their child’s needs. One-third of parents stated that their child’s eduators knew nothing of prematurity. Factors that enhanced educators’ performance on assessment of knowledge were: having taught a preterm child or a child with an individualized education plan in their class, and additional qualifications of the educator.

CONCLUSION: Educators and parents are unprepared to address the academic needs of preterm infants. Educators need to be trained on the outcomes of PTB and parents should be prepared to advocate for their child in the school system.
3-Year Survival and Neurodevelopmental Outcomes in Extremely Premature Neonates: A 15-Year Odyssey
Authors: Bhattacharya S , Miller M , Coughlin K
Published: September 2022

BACKGROUND: For neonates born at limits of viability, CPS recommends resuscitation decisions should occur after detailed discussion with parents, utilizing best available data on survival and neuro-developmental morbidities. There are emerging studies reporting such outcomes beyond 18-24 months. However, there is a notably wide variation in survival and rates of long term morbidity reported in the literature for infants born before 26 weeks of gestation. Centre specific survival rates among actively resuscitated extremely premature neonates and accurate developmental outcome data that truly reflects functional abilities are crucial for both parents and healthcare providers.

OBJECTIVES: Assess mortality, neuro-developmental outcomes at 3 years of age and correlate with risk factors predictive of adverse developmental outcomes in neonates born between 23+0-26+6 weeks of gestation at a tertiary care center in Ontario, Canada

DESIGN/METHODS: This was a retrospective analysis at a Level 3 center focusing on neonates born at 23+0 to 26+ 6 weeks gestation between January 2000 to December 2014. Data was extracted from Neonatal-Perinatal Database and Developmental Clinic Database. Clinical assessment of motor impairment (GMFCS), sensory impairment(blind or deaf) and a well validated tool Child Development Inventory were used to assess developmental outcomes at 3 yrs of age. Comparative analysis of possible risk factors, extracted from the NICU database , for adverse outcomes were analyzed using multivariate regression.

RESULTS: Survival rate among actively treated neonates were 25%, 60.4% and 77.5% at 23, 24 and 25 weeks respectively. 3 year survival rates with no major motor or neuro-sensory impairment were 40% among survivors born at 23 weeks, 47.2% among those born at 24 weeks, 55.6% and 68.6% among those born at 25 and 26 weeks respectively. Those born at 23 weeks had a significantly higher risk of having CP compared to the risk at 26 weeks [OR 9.04 {CI 1.96-41.67}]. Presence of IVH [OR 2.50 {CI 1.20-5.21}] and CSF infections [OR 5.71 {CI 1.03-31.56}] were identified as significant risk factors for adverse motor outcomes. Female neonates across all gestational age groups had significantly lower C P, speech delay and significantly better CDI scores. CDI profile analysis showed that at 3 years, nearly 80% of neonates born between 24-26 weeks have normal General Development Score, while only 40% of neonates born at 23 weeks had normal General Development Score at 3 years.

CONCLUSION: Being born at 23 week increased risk of cerebral palsy when compared to risk of birth at 26 weeks. CSF infection and IVH were found to be significant risk factors for adverse motor outcomes. The functional abilities as per the CDI Profiles were remarkably similar among survivors born at 24, 25,26 weeks of gestation.
The Effect of Umbilical Cord Milking on Hemodynamic Status of Preterm Infants: A Randomized Controlled Trial
Authors: El-Naggar W , Simpson D , Hussain A , Armson A , Dodds L , Warren A , Whyte R , McMillan D
Published: September 2022

BACKGROUND: Delayed cord clamping may be difficult to perform in extremely preterm infants. The effects of the alternative, cord milking, have not been fully evaluated.

OBJECTIVES: To determine whether cord milking (CM) at birth improves systemic blood flow and short term outcomes, as compared with immediate cord clamping (ICC).

DESIGN/METHODS: Babies born to eligible, consenting women presenting in preterm labor between 24 and 31 weeks' gestation were randomized to receive CM or ICC. Echocardiography was performed at 4-6 and 10-12 hours after birth. The primary outcome was systemic blood flow as represented by echo-derived superior vena cava (SVC) flow. Neonatal care staff, echogardiographer and interpreter were blind to the randomization. Analysis was by intention to treat.

RESULTS: A total of 73 eligible infants were randomized (37 to CM and 36 to ICC) during the study period (November 2011-2014). There were no statistically significant differences in maternal demographic and antenatal variables. Mean (SD) gestational age was 26.1 (11) weeks and mean (SD) birth weight was 1025 (308) g. 38% of infants were born by vaginal delivery. No significant differences were found between groups in SVC flow, cardiac outputs or neonatal morbidities [table1].

CONCLUSION: There were no statistically significant differences in functional cardiac outcomes, mortality or morbidity between preterm infants who received CM and those who received ICC. Larger trials are needed to establish the best practice in managing the umbilical cord at birth in extremely preterm infants.
Epidemiology of Posthemorrhagic Ventricular Dilatation in Canadian Neonatal Intensive Care Units
Authors: Afifi J , Vincer M , Shah V , Ye X , Shah P , Barrington K , Piedboeuf B , Kelly E , El-Naggar W
Published: September 2022

BACKGROUND: Severe intraventricular hemorrhage (IVH) is a common cause of neonatal morbidity and mortality .The incidence and management of post-hemorrhagic ventricular dilatation (PHVD) vary among different centres.

OBJECTIVES: To assess the incidence, temporal trend, management and associated outcomes of PHVD in Canadian NICUs.

DESIGN/METHODS: We conducted a retrospective review of all pre-term infants (22+0 -32+6 weeks) who were admitted to NICUs participating in the Canadian Neonatal Network between 2010 and 2014. Infants with severe IVH (IVH with ventricular dilatation or parenchymal bleeding) who survived ≥ 72 hours were included. We compared the rates of severe IVH, PHVD and VP shunting between the 5 Canadian regions. Short-term outcomes of infants who developed PHVD (ventricles size ≥10 mm) were compared with those who did not.

RESULTS: Of 16600 eligible infants, 1964 (11.8%) developed severe IVH. Of 1815 infants with severe IVH who survived ≥72 hours, 616 (34%) developed PHVD and 91 (5%) treated with VP shunt. No significant difference in the incidence of severe IVH, PHVD or VP shunting over the last five years was noted. There was a statistically significant difference in the rates of severe IVH (p<0.0001) and PHVD (p=0.02) among the 5 Canadian regions. VP shunts rates were variable with some Canadian regions with higher rates of PHVD had low rates of VP shunts. [figure 1]. Infants with PHVD had significantly higher mortality and short term morbidities. [table 1]. On regression analysis, PHVD is an independent predictor of death in infants with severe IVH [adjusted OR 1.55, 95% CI (1.18, 2.04)]. Infants with VP shunt had significantly higher rates of severe ROP (p<0.0001), meningitis (p<0.0001), and hospitalization (89 vs 41 days, p<0.0001).

CONCLUSION: PHVD is an independent predictor of death and is associated with adverse short- term outcomes. Variability exists between different regions in managing PHVD. Further studies are needed to investigate the impact of this variability on long-term outcomes.
The Relationship between Milk Fat Content, Vitamin D and Adiposity in Early Childhood
Authors: Vanderhout S , Maguire J , Birken C , Parkin P , Lebovic G , Chen Y , O'Connor D
Published: September 2022

BACKGROUND: Fortified cow’s milk is the main dietary source of vitamin D and an important source of dietary fat for North American children. Current guidelines recommend reduced milk fat consumption to reduce childhood obesity, yet the relationship between lower milk fat, vitamin D stores and adiposity is unclear.

OBJECTIVES: The objective of this study was to determine the association between percent fat content of milk and both zBMI and 25-hydroxyvi-tamin D; secondly, to explore if volume of milk consumed modified this relationship.

DESIGN/METHODS: A cross-sectional study of healthy urban children 12-72 months of age was conducted. Bivariate multiple linear regression was used to test the association between percent milk fat content and child 25-hydroxyvitamin D and zBMI concurrently. The interaction between volume of milk consumed and percent milk fat content was examined to explore how milk volume might modify these relationships.

RESULTS: 2745 children were included in the analysis. Percent fat content of milk was positively associated with 25-hydroxyvitamin D (p=0.006), and negatively associated with zBMI (p<0.0001). Children who drank homogenized milk (3.25% fat) had 6.6 nmol/L (95% CI 5.49 to 7.71) higher median 25(OH)D concentration and 0.72 lower (95% CI 0.68 to 0.76) zBMI score than children who drank skim milk (0.1% fat). Volume of milk consumed potentiated the effect of percent fat content of milk on 25-hydroxyvitamin D (p=0.003) but not on zBMI (p=0.77). Children who drank 1 cup of homogenized milk each day had a similar 25-hydroxyvita-min D as children who drank 2.85 cups (95% CI 2.71 to 2.99) of skim milk, but had zBMI score 0.78 (95% CI 0.63, 0.93) units lower.

CONCLUSION: Homogenized milk may be more appropriate than reduced fat milk in maximizing serum 25-hydroxyvitamin D and minimizing adiposity in early childhood. Current guidelines for reduced milk fat consumption in childhood may require further study to achieve desired outcomes.
Characteristics and Trends in Intentional Acetaminophen Intoxication in Adolescents Over Two Decades
Authors: Caudron M , Gosselin-Papadopoulos R , Jamoulle O , Swaleh S , Taddeo D , Frappier JY
Published: September 2022

BACKGROUND: Acetaminophen is a common drug used for self-poisoning in adolescents, and an important cause of acute liver failure in the pediatric population. Data regarding intentional acetaminophen intoxication in Canadian youths is limited.

OBJECTIVES: The purpose of the study was to describe the characteristics of intentional acetaminophen intoxications in Canadian adolescents and evaluate its evolution over two decades.

DESIGN/METHODS: We performed a retrospective chart review of intentional acetaminophen ingestions in adolescents (11-18 years old) hospitalized at a Canadian pediatric tertiary care centre between 1989 and 2009. We recorded the patients’ sociodemographic data, as well as the characteristics, complications and treatments of the intoxications. Data was compared across approximately five year periods as a group, then in both sexes separately.

RESULTS: A total of 383 cases were examined, 53 of which were in male patients and 330 in female patients. Given the small number of male patients, only female patients were included in this analysis. There were 200 cases within the time intervals 1 and 2 (1989-1993, 1994-1998) and 130 cases within the time intervals 3 and 4 (1999-2003, 2004-2009). Demographics were relatively constant across the time periods. Impulsive gestures were indicated as the motivation in almost 80% of cases, which remained stable over time (p=0.56). The ingestion of additional substances and the quantity of acetaminophen also remained constant over time (p=0.79 and p=0.46). Mean time to physician consultation significantly increased in time from 6h in interval 1 to 13.4h in interval 4 (p=0.0001). The proportion of ICU admissions, coagulopathy and multiple organ failures also increased across time intervals (p=0.01, 0.03 and 0.03 respectively). There was no definitive linear trend in cases of hepatitis, encephalopathy or acute kidney injury (p=0.26, 0.81 and 0.27 respectively). There were two deaths, and one liver transplant over the 21-year period. Treatment significantly changed over time with progressive increase in N-acetylcysteine use from 47.4% to 81.1% (p=<0.0001) and progressive decline in charcoal use from 70.2% to 17.6% (p<0.0001) in intervals 1 to 4. Poison centre consultations significantly increased in time from 14.4% in interval 1 to 67.7% in interval 4 (p<0.0001).

CONCLUSION: We suggest that the apparent severity increase in adolescent acetaminophen intoxication is related to the progressive increase in time to physician consultation with associated delays in treatment. The changes in management observed over the 21-year period is likely reflective of the evolution and availability of treatment protocols. Furthermore, the increase in poison centre consultations may account for part of the decrease in treatment variability across patients.
Do Children with Adhd Show Improvements in Memory and Behaviour When Stimulant Medication Dosage is Titrated?
Authors: Lemay JF , Kubas H , Witzke J , Murphy K , Bergstrom N , McKee J
Published: September 2022

BACKGROUND: Attention-deficit/hyperactivity disorder (ADHD) is a neurodevelopmental disorder that often negatively impacts behaviour, memory, cognition, and academic achievement. Children with ADHD also exhibit deficits in executive functioning (EF). Currently, stimulant medications are the most commonly used treatment for ADHD; however, finding an ideal dose remains a challenge in the day-to-day practice of pediatricians. Medication titration is a possible option that might help in treatment.

OBJECTIVES: 1) to determine if children with ADHD show improvements in both memory and behaviour when long active methylphenidate (MPH) medication dosage is titrated; 2) to report if differences exist in memory/behaviour results relative to baseline and placebo conditions.

DESIGN/METHODS: A randomized controlled MPH medication trial was conducted with children ages 8-12 with a diagnosis of ADHD. Participants began with 1-week of baseline assessment, followed by a randomized 3-week trial order of placebo, low MPH dose, and high MPH dose. The Wisconsin Selective Reminding Test (WSRT) was used to measure long-term memory storage, retrieval, and learning (memory component) and the Behavior Rating Inventory of Executive Function (BRIEF) was used to measure parental perceptions of EF (behavioural component). These neuropsychological and behavioural assessment results were then graphically depicted and an optimal “best dose” determined for each child that was most effective in improving memory and behaviour. Also, a repeated-measures ANOVA was run to compare between baseline, placebo, and best dose conditions.

RESULTS: A total of 19 children (10 males, 9 females) ages 8-12 (M = 10 years±1.3 years) were enrolled. Statistically significant improvements were noticed on the WSRT (F range = 22.30–48.17, p<.001), and on the BRIEF (F=22.68, p<.001) during the “best dose” condition relative to baseline and placebo. These improvements were similar across most measures for both males and females. In addition, no significant differences were noted between the baseline and placebo conditions for any measure on both the WSRT and BRIEF (F range 0 – 4.11, p range .061 – .994).

CONCLUSION: When neuropsychological and behavioural test results are used to titrate medication and help with “best dose” selection, MPH appears to improve both memory and behaviour in children with ADHD. Overall, no differences were observed between baseline and placebo. Thus, a better understanding of memory and behavioural dose-response relationships may ultimately lead to targeted intervention plans that help foster long-term treatment efficacy in these ADHD children.
Using Art as a Medium for First Nations Youth to Express Their Pain: A Two-Eyed Seeing Qualitative Study
Authors: Latimer M , Rudderham S , Harman K , Finley A , Dutcher L , Hutt-Macleod D , Paul K
Published: September 2022

BACKGROUND: First Nations (FN) youth in Canada have the highest rates of pain-related conditions (ear, dental, headaches) yet may be least likely to be treated for them. Untreated pain has an arresting impact on growth and development and is detrimental to the achievement of life goals. In recent research conducted by the Aboriginal Children’s Hurt & Healing Initiative (ACHH), community participants reported that First Nation children are stoic and are reluctant to talk about their pain (Latimer & Rudderham, 2013). Clinicians are trained to assess pain based on overt signs of expression (cry, facial grimace, ability to describe) however if you do not present your pain this way it may reduce the chance of proper assessment and treatment.

OBJECTIVES: Using a Two-Eyed Seeing qualitative perspective (best of Indigenous and Western knowledge) the purpose of this research was to provide FN youth with the method of art making to determine how they express their pain.

DESIGN/METHODS: Youth from four FN communities, in three Maritime Provinces were invited to participate in art workshops facilitated by internationally renowned Mi’kmaq artist Alan Syliboy. The workshop began with a conversation circle about pain experiences and then proceeded to the art making. A FN documentary cinematographer captured the workshops and the results are documented in art and film. Three team members independently themed the data using thematic analysis and the inter-rater reliability was >85%.

RESULTS: 39 youth aged 10-18 years participated in 4 community-based conversation and art sessions. The themes for the sessions were themed using the four dimensions of the Medicine Wheel. While the overwhelming theme discussed in the conversation sessions was physical pain, when provided the nonverbal, art mode of expression, the youth painted emotional pain more frequently than physical, spiritual and mental pain. There was overlap between the four themes but 70% of the artwork prominently illustrated emotional pain with 54% overlapping with physical, 30% mental and 31% spiritual.

CONCLUSION: These results present a more complicated issue regarding the integration of the different types of pain, intertwined together. The finding that when asked-youth primarily discussed physical pain but given the opportunity, more frequently painted emotional pain may shed new light on the degree to which emotional pain is a factor for these youth. The artwork and accompanying narratives are powerful and have implications for understanding the complexity of assessing the different dimensions of pain in a culturally meaningful manner and for clinician education purposes. A sample of the artwork is attached.
Limited Access to Facial Feminization Geographically Despite Nationwide Expansion of Other Gender-Affirming Surgeries
Authors: Hauc Sacha C. , Mateja Kirby L. , Long Aaron S. , Glahn Joshua Z. , Acuna Higaki Adrian R. , Rivera Jean Carlo , Ihnat Jacqueline M. H. , Mukherjee Thayer , Oh SeungJu Jackie , Alperovich Michael
Published: September 2022

Background:

Facial feminization surgery (FFS) is an integral aspect of gender-affirming surgery (GAS) for individuals seeking to align secondary sex characteristics and gender identity. Despite the importance of FFS in treating gender dysphoria, current trends and prevalence remain unknown. We sought to examine trends in GAS and FFS and investigate the payer status of facial feminization procedures in the United States.

Methods:

Data was extracted from the National Inpatient Sample from 2008 to 2017 by using International Classification of Diseases Ninth or Tenth diagnosis codes for gender identity disorder and procedure codes for FFS.

Results:

From 2008 to 2017, 3015 patients underwent GAS. The yearly number of cases increased as did the average cost of GAS, which rose from $13,657 in 2008 to $50,789 in 2017. From 2015 to 2017, when FFS data was available, 110 of 1215 (9.1%) GAS patients had FFS. Most were non-Hispanic White (66.7%) or Black (23.8%). Fifty percent of FFS cases occurred in the West, followed by the Northeast (31.8%), South (13.6%), and Midwest (4.8%) (P = 0.015). By payer the cases were, 36.4% self-pay, 31.8% Medicaid, and 27.3% private insurance (P < 0.0001). Approximately, 18% of patients undergoing male-to-female transition received FFS.

Conclusions:

From 2008 to 2017, GAS cases increased nationwide while the average cost of surgery rose steeply. FFS cases were primarily in the Western and Northeast United States. Despite high cost, roughly 18% of transgender women in our sample received FFS, highlighting the importance of FFS in gender transition.
Improving Foodborne Disease Surveillance and Outbreak Detection and Response Using Peer Networks—The Integrated Food Safety Centers of Excellence
Authors: White Alice E. , Garman Katie N. , Hedberg Craig , Pennell-Huth Paula , Smith Kirk E. , Sillence Elizabeth , Baseman Janet , Scallan Walter Elaine
Published: September 2022

Context:

Foodborne disease surveillance and outbreak investigations are foundational to the prevention and control of foodborne disease in the United States, where contaminated foods cause an estimated 48 million illnesses, 128 000 hospitalizations, and 3000 deaths each year. Surveillance activities and rapid detection and investigation of foodborne disease outbreaks require a trained and coordinated workforce across epidemiology, environmental health, and laboratory programs.

Program:

Under the 2011 Food Safety Modernization Act, the Centers for Disease Control and Prevention (CDC) was called on to establish Integrated Food Safety (IFS) Centers of Excellence (CoEs) at state health departments, which would collaborate with academic partners, to identify, implement, and evaluate model practices in foodborne disease surveillance and outbreak response and to serve as a resource for public health professionals.

Implementation:

CDC designated 5 IFS CoEs in August 2012 in Colorado, Florida, Minnesota, Oregon, and Tennessee; a sixth IFS CoE in New York was added in August 2014. For the August 2019-July 2024 funding period, 5 IFS CoEs were designated in Colorado, Minnesota, New York, Tennessee, and Washington. Each IFS CoE is based at the state health department that partners with at least one academic institution.

Evaluation:

IFS CoEs have built capacity across public health agencies by increasing the number of workforce development opportunities (developing >70 trainings, tools, and resources), supporting outbreak response activities (responding to >50 requests for outbreak technical assistance annually), mentoring students, and responding to emerging issues, such as changing laboratory methods and the COVID-19 pandemic.
Assessing Risks of Early Childhood Caries in Primary Care Practice Using Electronic Health Records and Neighborhood Data
Authors: Tuan Wen-Jan , Leinbach Leah I. , Gill Stephanie A.
Published: September 2022

Context:

Early childhood caries (ECC) is a persistent public health challenge, affecting more than 56% of US toddlers and preschool-aged children. Despite this, ECC is largely preventable with routine oral hygiene practices, diet, and application of topical fluoride.

Objective:

This study assessed the utilization of preventive oral health care in primary care practices and evaluated the variation in patient characteristic and geographic disparities.

Design:

We conducted a retrospective study using electronic health records (EHRs) over a 2-year period. Patients' home addresses were geocoded and linked to census-based neighborhood statistics and fluoridated water accessibility. Multiple logistic regression modeling was used to assess the risk of ECC in patients with fluoride preventive care, controlled for demographics, comorbid conditions, and neighborhood risk factors.

Participants:

Patients aged 6 to 71 months who had primary care providers at family medicine and general pediatric clinics in a large academic medical center.

Main Outcome Measure:

The presence of dental caries based on diagnoses in EHRs.

Results:

The study consisted of 10 836 patients: 17% treated with topical fluoride varnish (TFV), 12% prescribed oral fluoride supplement, 6.1% with both TFV and supplement, and 64% without fluoride treatment. Patients with fluoride treatment were 24% to 53% less likely to have ECC. Children living in rural and nonfluoridated water communities had 1.7 to 1.8 times greater risk of developing ECC. Minority, under/uninsured, and low-income patients also were at an increased risk of ECC.

Conclusion:

Despite continuing efforts to improve access to dental care for vulnerable populations, substantial disparities remain among socioeconomically disadvantaged children. To address dental care shortage, primary care clinicians should serve as the safety net to care for vulnerable and underserved children who have no or limited access to oral health services. Future research into the collaboration between primary care and dental providers at the level of both practice and professional education should be considered.
Duration of Treatment With Glucocorticoids in Giant Cell Arteritis
Authors: Moreel Lien , Betrains Albrecht , Molenberghs Geert , Blockmans Daniel , Vanderschueren Steven
Published: September 2022

The aim of this meta-analysis was to estimate the mean duration of glucocorticoid (GC) treatment in patients with giant cell arteritis. PubMed, EMBASE, and Cochrane databases were searched from inception until November 30, 2021. The outcome measures were the proportion of patients on GCs at years 1, 2, and 5 after diagnosis and the mean GC dose (in the entire cohort and expressed in prednisone equivalents) at these time points. Twenty-two studies involving a total of 1786 patients were included. The pooled proportions of patients taking GCs at years 1, 2, and 5 were 89.7% (95% confidence interval [CI], 83.2%–93.9%), 75.2% (95% CI, 58.7%–86.6%), and 44.3% (95% CI, 15.2%–77.6%), respectively. The pooled GC dose at years 1 and 2 was 9.1 mg/d (95% CI, 2.8–15.5 mg/d) and 7.8 mg/d (95% CI, 1.4–14.1 mg/d), respectively. The proportion of patients taking GCs at year 1 was lower in multicenter studies (p = 0.003), in randomized controlled trials (p = 0.01), and in studies using a GC-tapering schedule (p = 0.01). There were no significant differences in the proportion of patients taking GCs at years 1 and 2 according to study design (retrospective vs. prospective), initial GC dose, use of pulse GCs, publication year, enrolment period, duration of follow-up, age, and sex. This meta-analysis showed that giant cell arteritis is a chronic disease that requires substantial and prolonged GC treatment in a considerable proportion of patients. A predefined GC-tapering schedule may help to avoid inadequately long GC treatment.