bluuebunny/crossref_metadata_2025 huggingface dataset:
A Randomized Controlled Trial on Oral Analgesic Utilization for Children Presenting With A Musculoskeletal Trauma in the Emergency Department
Authors: May S Le , Ali S , Plint A , Mâsse B , Neto G , Auclair M C , Drendel AL , Khadra C , Ballard A , Villeneuve E , Parent S , McGrath P , Gouin S
Published: September 2022

BACKGROUND: A single-agent approach to children’s moderate to severe pain is often inadequate. To date, no studies have evaluated the combined use of oral morphine and ibuprofen for optimal pain management of children presenting to an emergency department (ED) for muscu-loskeletal (MSK) trauma.

OBJECTIVES: To assess the efficacy of a combination of oral morphine and ibuprofen for pain management in children with MSK trauma in the ED.

DESIGN/METHODS: A double-blind, placebo-controlled, multi-centered, three-arm, randomized clinical trial of 500 patients was conducted at three pediatric tertiary care EDs. Patients were randomized (in a 2:1:1 ratio) to receive (orally): (a) morphine (0.2mg/kg) + ibuprofen (10mg/kg) (Group MOR + IBU) or (b) morphine (0.2 mg/kg) + placebo (Group MOR) or (c) ibuprofen (10mg/kg) + placebo (Group IBU). Patients 6 to 17 years of age, who presented to the ED with a MSK trauma, and a score >30 mm on the 100mm visual analogue scale were eligible to participate. Primary outcome was pain intensity score under 30 mm (mild pain) at 60-minutes (T-60) after treatment administration.

RESULTS: A total of 456 patients were included in analyses: 177 (MOR + IBU), 188 (MOR), 91 (IBU). Mean age was 11.9±2.7 years, with a majority of boys (55.3%) and Soft tissue injuries (62%). There were no differences in baseline characteristics in the three groups. Baseline mean pain score was 60.9±16.2 mm. Only 30% (MOR + IBU), 29% (MOR) and 30% (IBU) of patients reached a pain score under 30 mm at T-60 (p=0.83). Mean pain scores at T-60 were 42.3±23.2 mm (MOR + IBU), 43.8 + 23.1 mm (MOR) and 42.3±23.3 mm (IBU) (p=0.83). No severe adverse events were observed in any of the groups, at any of the study measurement points.

CONCLUSION: Combination of morphine with ibuprofen did not provide any additional pain relief for children with MSK injuries, in the ED. None of the study medication provided optimal pain management, as the majority of children did not reach the WHO definition of mild pain. Alternative analgesic combinations should be investigated to optimize pain relief of children who present to the ED with MSK injuries.
Evaluation of An Oral Morphine Protocol for Treatment of Acute Pain Crisis in Sickle Cell Patients in the Outpatient Setting
Authors: Paquin H , . Trottier E D. , Pastore Y , Robitaille N , Doré Bergeron M-J , Bailey B
Published: September 2022

BACKGROUND: Sickle cell vaso-occlusive crisis (VOC) is one of the most frequent causes of emergency visit and admission in children with this condition.

OBJECTIVES: To evaluate whether the implementation of an oral morphine protocol has led to improved care of sickle cell disease (SCD), translated by a reduced hospitalization rate, an increased oral administration rate and faster opiate administration time, comparing cohorts of patients presenting to the emergency department (ED) and hematology outpatient clinic (HOC) with VOC pre and post implementation.

DESIGN/METHODS: Retrospective chart review of patients with SCD followed at CHU Ste-Justine, who presented to the ED and HOC with VOC, in the year pre and post implementation of the protocol. Patients with a VOC diagnosis during the study periods were selected in each department’s database. The primary outcome was to evaluate the hospital-ization rate. The rate of oral administration, as well as the opiate administration time from inscription in the ED or arrival in the HOC were also calculated. We estimated that 35 patients per arm would be sufficiently powered to detect at least a 30% rate reduction of admissions, with a power of 80% and a significance of 0.05.

RESULTS: Over the two periods, a total of 105 patients (49 pre and 56 post) were included from the ED and 62 patients (36 pre and 26 post) from the HOC. Both departments showed a reduction in hospitalization rate: a difference of 48% (95% CI 32, 61) in ED and 38% (95% CI 13, 57) in HOC. Both showed an increase in the rate of oral administration: a difference of 36% (95% CI 19, 50) in ED and 33% (95% CI 8, 53) in HOC. There was a non-significant difference of 10 min (95% CI -10, 25) in the opiate administration time in ED, as opposed to HOC where a significant difference of -45 min (95% CI -71, -6) was found, with both presenting median times over the recommended 60 minutes post implementation. Both settings showed an increase in the percentage of patients without IVs; a difference of 17% (95% CI 4, 30) in ED and 55% (95% CI 72, 31) in HOC.

CONCLUSION: This study validates the use of our oral morphine protocol for the treatment of VOC, by showing a significant reduction in hospi-talization rates. Although delays remain in our opiate administration time, our protocol decreased the number of painful IV procedures.
Decreases in Rotavirus Hospitalizations: Impact Data Pre- and 3 Years Post- First Publically Funded Programs
Authors: Saux N Le , Halperin S , Vaudry W , Scheifele D , Bettinger J
Published: September 2022

BACKGROUND: Since January 2012, almost all Canadian provinces have implemented publically funded rotavirus immunization programs. IMPACT had been doing routine active surveillance for rotavirus hospital-izations at pediatric hospitals in 7 provinces since 2005.

OBJECTIVES: Determine changes in hospitalization for rotavirus infection pre and post vacination programs.

DESIGN/METHODS: Active, surveillance of patients hospitalized for rotavirus infections was conducted by IMPACT from January 1 2010 to December 2015 at 12 paediatric hospitals. Rotavirus hospitalization data was compared for periods pre (2010-2011) and post (2012-2014) implementation of publically funded immunization programs. Six sites were located in jurisdictions that had publically funded programs as of January 2012.

RESULTS: Initiation of rotavirus vaccine programs have resulted in a 43% overall reduction in hospitalizations for rotavirus infection in pediat-ric hospitals in Canada with the greatest decreases seen in provinces with programs that were established as of January 2012 where there was a 66% reduction in hospitalizations. Overall, the average yearly number of hospi-talizations for 2012-2014 was 279, compared to 490 in 2010-2011. Six sites with publically funded programs since 2012 had a yearly average of 121.3 cases identified in 2012-2014 compared to an average of 360 cases in 2010-2011. The average yearly number of hospital acquired cases decreased from 78 to 24.7 in sites with vaccine programs whereas sites without increased (26.5 to 33.7 average cases yearly). The proportion of cases occurring in children <2 years was significantly lower in sites with programs (51.6% vs. 72.5%; p<0.0001). In 2012-2014, 63.4% of children were <2 years compared to the period 2010-2011 where 67.7% were <2 years. The seasonal peak in infections has decreased over time, especially in the age groups 6-11 months and 12 to 24 months.

CONCLUSION: Publically funded rotavirus vaccine programs have resulted in important reductions in hospitalizations due to community acquired and hospital acquired rotavirus infections in pediatric hospitals in Canada with the greatest decreases seen in provinces with programs that were established as of January 2012. The proportion of children < 2 years hospitalized with rotavirus infection is decreasing at sites with established programs. Given the >85% efficacy of rotavirus vaccine, increasing uptake and delivery throughout Canada could potentially decrease admissions further.
Sexual Health of Adolescents Admitted to A Psychiatric Unit
Authors: Zanten S Van , Noel A , Gresham L , Boafo A , Norris M , Robinson A , Turner D , Harrison M , Chan J
Published: September 2022

BACKGROUND: Research suggests an association between certain psychiatric conditions and high-risk adolescent sexual activity. In fact, pregnancy is three times more likely in adolescent girls with major mental health disorders in comparison to those without mental illness. Given a proportion of adolescents with mental health disorders will require admission to the hospital for acute psychiatric concerns, this could serve as a useful time point to screen for risky sexual behaviour in high-risk youth.

OBJECTIVES: Our objective was to review the history screening practices at admission and throughout an inpatient stay for adolescents on an inpatient psychiatry unit and to review any resulting referrals or treatment relating to sexual health.

DESIGN/METHODS: A chart review was conducted which included one hundred randomly selected adolescent patients admitted to an inpa-tient psychiatry unit over a 12 month period (January 2013-December 2013). Measures extracted from charts included demographic information, reason for admission, psychiatric diagnoses, documented sexual health related data and any investigations, co-morbidities, treatment and/or follow up booked related to sexual health. Ethics approval was obtained prior to study onset.

RESULTS: The majority of patients were female (79%) and the mean age of study subjects was 15.24 (SD=1.30). The majority of patients admitted received a discharge diagnosis of a major depressive disorder (57%) and the mean length of stay was 11.14 days (SD=7.75). Of the patients admitted, 85% did not appear to have sexual health questions asked on admission and 61% did not have any documented sexual health questions asked throughout their inpatient admission. 17% of patients had sexual activity information documented and very few patients had any STI screening or pregnancy testing (9 patients and 14 patients, respectively).

CONCLUSION: Adolescents with major mental health disorders may be at increased risk for risky sexual behaviours. We found that sexual health practices were only addressed in a minority of patients during their inpatient psychiatric admission. This interaction with the health care system represents an underutilized opportunity to provide counselling and anticipatory guidance to adolescents regarding their sexual health.
Association between Rome III Diagnostic Criteria and Treatment Failure in Children Brought for Emergency Department Care
Authors: Eltorki M , Martin E
Published: September 2022

BACKGROUND: Many children diagnosed with functional constipation (FC) in the ED in fact meet Rome III criteria for irritable bowel syndrome constipaion subtype (IBS-C). The frequency of this misdiagnosis and its relation to outcomes is unknown.

OBJECTIVES: To determine if treatment failure frequency differs based on Rome III diagnostic criteria classification in a cohort of ED children diagnosed by treating physicians as having constipation.

DESIGN/METHODS: We performed a prospective cohort study of children 1 month – 18 years of age who were diagnosed with or were treated as FC in a pediatric ED. ED chart data was abstracted and a follow-up call was performed 7 days post-ED visit to enable the completion of the ROME III functional intestinal disorder questionnaire, confirm treatments administered, and enable symptom resolution assessment. 'Adequate therapy' was defined in accordance with ESPGHAN/NASPGHAN consensus guidelines. Treatment failure was defined by ≥2 of the following: persistence of presenting symptom(s), bowel movement frequency <1 every other day, pain or difficulty passing stools, abdominal pain between bowel movements, and/or persistence of the ED chief complaint.

RESULTS: 929 potentially eligible children were identified; 237 were excluded. We failed to contact 162 patients and 17 refused consent. 513 (74%) completed day 7 follow up – 227 (44%) met FC ROME III criteria, 119 (23%) met IBS-C criteria and 167 (33%) did not meet IBS-C or FC criteria and were classified as ‘other’. Mean age was 6.1±3.9 years. Treatment failure occurred in 69 (30%) FC patients, 50 (43%) of those with IBS-C, and 41 (25%) of ‘other’ group; P=0.007. These differences persisted when only those receiving ‘adequate therapy’ (n=308) were included: 41 (28%) of FC and 16 (22%) of those in the ‘other’ group had persistent symptoms compared to 37 (43%) of IBS-C patients; P=0.008. Kaplan-Meier analysis revealed greater symptom persistence in children with IBS-C compared to those with FC (P<0.001). Those classified as FC were more likely to have abdominal distension (P=0.05) and tenderness (P=0.04) compared to the IBS-C.

CONCLUSION: Children diagnosed with constipation in an ED who fulfill ROME III irritable bowel syndrome (constipation subtype) criteria have a higher treatment failure rate at day 7 compared to functional constipation even when including only those who received adequate functinal constipation therapy. ROME III criteria can be employed to identify children with irritable bowel syndrome; such children might benefit from diagnosis specific therapy.
Successful Implementation of a Change in Practice to Optimize Timing of Umbilical Cord Clamping in Preterm Neonates: A Quality Improvement Initiative
Authors: Irvine L , Abou Mehrem A , Singhal N , Thomas S , Cooper S
Published: September 2022

BACKGROUND: Natural, also known as delayed, umbilical cord clamping (NCC) is recommended for at least 60 seconds (s) in preterm infants. However, changing the institutional guidelines only may not result in satisfactory adoption and change in practice.

OBJECTIVES: To determine if a structured multidisciplinary educational approach during the implementation of the new guideline of NCC in pre-term infants will result in over 50% compliance rate.

DESIGN/METHODS: The evidence supporting NCC was presented in a grand round to all health care providers involved in maternal-newborn care. A multidisciplinary team comprised of neonatologists, obstetricians, neonatal nurse practitioners, respiratory therapists and nurses developed NCC clinical practice guideline. Local champions at each of the 4 city hospitals were identified to create change in culture and establish lines of open communication between disciplines. Following completion of education of all staff involved in delivery room care, formal implementation of NCC began October 2013 for gestational age (GA) 33-35 weeks, January 2014 for GA ≥28 weeks, and April 2014 for GA ≥26 weeks. Data were collected from October 2013 until April 2015.

RESULTS: Table 1 shows the compliance rates and the proportion of infants who received NCC ≥45s. In addition, we found that 18% of infants 26-32 weeks GA deemed eligible for NCC, received cord clamping at <45s to facilitate resuscitation.

CONCLUSION: Compliance with practice change can be successfully achieved through a structured team approach, establishing open lines of communication, and frequent feedback to the front line members. Further research may lead to more infants qualifying for and resuscitated during NCC.
Assessment of Gluten Exposures in Children with Celiac Disease
Authors: Brill H , Dowhaniuk J , Cheng J , Pai N , Mileski H , Tutelman P , Saab J
Published: September 2022

BACKGROUND: Celiac Disease (CD) is one of the most common chronic diseases of childhood. A strict, lifelong gluten-free diet (GFD) remains the sole treatment for CD. Reports of accidental or intentional ingestion of gluten are common, but little is known about the sources or context of such exposures.

OBJECTIVES: We sought to ascertain the self-reported causes for gluten exposure for children with Celiac Disease.

DESIGN/METHODS: Parents of children with biopsy-proven CD followed at McMaster Children’s Hospital were asked to review a 22-item questionnaire listing sources, situations and causes of gluten exposure for their child. The questionnaire encompassed both intentional and unintentional gluten exposures and was developed through consultation with Registered Dietitians and Faculty in the Division of Pediatric Gastroenterology at McMaster Children’s Hospital. Children independently completed a similar 21-item questionnaire adapted for pediatric use. Participants were invited to describe any additional sources or circumstances leading to gluten consumption not captured in the questionnaire.

RESULTS: A total of 123 families participated in the study with a median of 32 months on a GFD. A minimum of one cause of gluten exposure was selected by 65% of parents and 60% of children. Restaurant dining was identified as a source of gluten consumption by 39% of parents, due to a lack of knowledge of the GFD by restaurant staff or poor labeling of menu items. Other commonly selected items on the parent questionnaire included: difficulty while traveling (13%), to avoid exclusion at social events (12%), and a lack of negative symptoms following gluten exposure (9%). Few parents identified cost (2%), or the availability of gluten-free food as a concern (5%). Children most commonly identified restaurant eating (32%), and the lack of any negative symptoms from eating gluten as the main causes of gluten exposure (14%). In this study population, 11% of children acknowledged consuming gluten because they felt left out at either home, school or with friends.

CONCLUSION: This study provides information about the common causes of gluten exposure for children with CD in Ontario, Canada. Restaurant dining and travel were the most commonly identified sources of gluten ingestion. Our study highlights the need for improved menu labeling and education of restaurant staff, requiring both policy changes and dialogue with food service industries. While availability of gluten-free products has greatly improved, exclusion from social activities remain a concern for both children and their parents. Further qualitative studies may build on these identified themes to better understand challenges families face with the GFD.
Hiv-Exposed but Uninfected Infants: Identifying Developmental Delay and the challenges faced in Accessing Developmental Services from a Canadian Tertiary Centre
Authors: Abdulwahab K , Olson L , Adjudani A , Pakzad Z , Alimenti A , Sauvé L
Published: September 2022

BACKGROUND: Children born to HIV-positive mothers but are HIV uninfected (HEU) are at increased risk for adverse developmental outcomes. The literature suggests that the increased risk is more related to social determinants of health rather than effects of perinatal exposures to HIV and antiretrovirals. Developmental screening and early referral do result in improved outcomes and so HEUs should benefit from anticipatory guidance and early specialist referral.

OBJECTIVES: We aimed to identify the rate of development screening, identification and referral of developmental concern, and referral completion in a provincial family-centered HIV clinic caring for 20-30 HIV exposed newborns per year and secondarily identify barriers to referral completion.

DESIGN/METHODS: We conducted a retrospective review of all of the HEU cared for at this outpatient clinic born between January 1, 2008 and June 30, 2013 to examine the frequency of developmental concerns, referral rates for children with documented concerns, and referral outcomes.

RESULTS: We reviewed 112 subjects: 64 (57%) male; 87 (77%) born at term (>37 weeks). 78 (66%) of the families had one or more social vulnerabilities (parental ill health apart from HIV, poverty, limited literacy, limited English language skills, etc), including 43 (38%) who had some involvement with child protection services. 104 (92.8%) had at least one documented developmental assessment using standardized tools. Among these 104, 46 (44.2%) were noted to have a developmental concern and of those, 40 (87.0%) were referred to at least one developmental service provider or general pediatrician. There were a total of 43 referrals to developmental service providers; 58.1% occurred at time of study completion, and 60.0% for which recommendations were formally communicated. Of 36 referrals to general pediatricians, 69.4% had occurred, 92.0% of which recommendations communicated back to the clinic. Barriers to referral completion included inability to contact caregivers (7.3%), patient no-show (13.0%), waiting lists (23.2%), and other (56.5%).

CONCLUSION: The large majority of patients were screened and referred when indicated, but a significant number of patients either were not assessed by the secondary provider, or no information was communicated back to the clinic. Multiple barriers at the clinic, patient, and referral centre level were identified. The discrepancy in referral completion between developmental service provider referrals and general pediatrician referrals, may further highlight the difficulty HEU families have navigating our provincial developmental services. Future work will examine how to overcome these barriers in a vulnerable population.
DESCRIPTION D’UNE COHORTE RÉTROSPECTIVE DE PATIENTS PÉDIATRIQUES ATTEINTS DE THROMBOPÉNIE IMMUNE AIGUË
Authors: Hendriks MC , Toussaint MP , Michon B , Veilleux-Lemieux M
Published: September 2022

BACKGROUND: La thrombopénie immune (TPI) aiguë est une condition fréquente dont la prise en charge demeure controversée. Les lig-nes directrices suggèrent de traiter les enfants présentant des saignements modérés ou sévères avec des corticostéroïdes ou des immu-noglobulines (IVIg).

OBJECTIVES: L’objectif principal est de décrire des patients pédiatriques atteints de TPI aiguë. Les objectifs secondaires sont de décrire les effets indé-sirables et les répercussions sur les soins associés au traitement par IVIg.

DESIGN/METHODS: Il s’agit d’une étude de cohorte rétrospective par révision de dossiers. Les patients inclus sont âgés entre 1 et 17 ans, atteints de TPI aiguë et ont été traités dans notre établissement du 2004-01-01 au 2014-06-01. La classification des saignements est définie selon celle utili-sée dans les lignes directrices.

RESULTS: Les 88 patients ont un âge moyen de 6.9 ans. À l’arrivée, 87/88 (98,9%) patients présentaient des saignements : 5/87 (5,7%) sévères, 24/87 (27,6%) modérés, 58/87 (66,7%) mineurs ou légers et aucun saigne-ment menaçant la vie (comme une hémorragie intracrânienne). Les pla-quettes initiales moyennes étaient de 11,0×109/L et 63/88 (71,6%) patients avaient un taux ≤10×109/L. Initialement, 77/88 (87.5%) patients ont été traités : 62/77 (80,5%) avec des IVIg, 8/77 (10,4%) avec des corticosté-roïdes et 3/77 (3,9%) avec les deux traitements combinés. 40/88 (45%) patients ont reçu plus d'un traitement, dont 23/40 (57,5%) en moins de 48 heures. 5/77 (6,4%) patients ont reçu une transfusion de plaquettes. Une réponse au traitement initial a été obtenue chez 62/77 (80,5 %) patients. Une TPI chronique s’est développée chez 15/88 (17,0%) patients. Parmi les patients ayant reçu des IVIg au moins une fois, 42/74 (56,8%) ont présenté des effets indésirables associés à ce produit sanguin dont 10/42 (23,8%) des nausées, 28/42 (66,7%) des vomissements et 31/42 (73,8%) des céphalées. Ceux-ci sont associés à une imagerie cérébrale chez 5/88 (5,7%) patients (toutes normales).

CONCLUSION: Notre étude démontre le caractère mineur des saigne-ments à la présentation initiale du patient avec TPI. Ceci appuie les lig-nes directrices qui limitent le nombre de patients traités. Malgré cette présentation par des saignements surtout mineurs ou légers, un grand nombre de patients est traité dans notre milieu et plus de 80% le sont avec des IVIg. Cette pratique semble associée à des effets indésirables et investigations supplémentaires, ce qui devrait être pris en compte lors du choix du traitement initial.
Predictors of Unintentional Injuries in Paediatric Immigrants in Ontario
Authors: Saunders N , Macpherson A , Guttmann A
Published: September 2022

BACKGROUND: Unintentional injury is a frequent reason for emergency department visits and is the leading cause of death for Canadian children. Injury is associated with a number of socio-demographic variables but it is not known whether being an immigrant changes this risk.

OBJECTIVES: To examine the association between family immigrant status and unintentional injury; and to test this relationship within immigrants by refugee status.

DESIGN/METHODS: Retrospective population-based cross-sectional study of children ages 0 to 14 years residing in Ontario, Canada from 2008 to 2012, using linked health administrative databases and Citizenship and Immigration Canada’s Permanent Resident Database. The main exposure was immigration status (immigrant or child of an immigrant vs. Canadian born). Secondary exposure was refugee status. Main outcome measure was unintentional injury events (emergency department visits, hospitaliza-tions, deaths), annualized. Data were analyzed using Poisson regression models to estimate risk ratios (RR) for unintentional injuries.

RESULTS: There were 11 464 317 injuries per year. Non-immigrant children sustained 12051 injuries/100 000 and immigrants had 6837 injuries/100 000, annually. In adjusted models, immigrants had a significantly lower risk of injury compared with non-immigrant children (RR 0.60; 95% confidence interval [CI] 0.57, 0.63). Overall, the most materially deprived neighbourhood quintile was associated with a higher rate of injury (RR 1.13; 95% CI 1.07, 1.02, quintile 5 vs. 1) whereas within immigrants, material deprivation was associated with a lower rate of injury (RR 0.96; 95% CI 0.94, 0.98, quintile 5 vs. 1). Other predictors of injury included age (0 to 4 years: RR 0.84; 95% CI 0.81, 0.88; 5 to 9 years: RR 0.70; 95% CI 0.67, 0.73), male sex (RR 1.30; 95% CI 1.26, 1.35), and rural residence (RR 1.50; 95% CI 1.43, 1.57). Injury rates were lower in immigrants across all types of unintentional injuries. Within immigrants, refugees had a higher risk of injury compared with non-refugees (RR 1.12; 95% CI 1.10, 1.14). This risk was particularly high for motor vehicle accidents (RR = 1.58; 95% CI 1.46, 1.71) and scald burns (RR 1.23; 95% CI 1.11, 1.35).

CONCLUSION: Risk of unintentional injury is lower among immigrants compared with Canadian-born children. These findings support a healthy immigrant effect. Socioeconomic status has a different effect on injury risk in immigrant and non-immigrant populations, suggesting alternative causal pathways for injuries in immigrants. Risk of unintentional injury is higher in refugees versus non-refugee immigrants, highlighting a population in need of targeted injury prevention strategies.
Burning the Midnight Oil: A Focus Group Study of Medical Student Night Call Preferences
Authors: Scott O , Novak C , Lee J , Forbes K
Published: September 2022

BACKGROUND: Call is an integral component of clerkship, providing unique clinical and educational opportunities. Recently, traditional call has been the subject of scrutiny, resulting in changes to call requirements. Canadian Pediatric clerkships currently employ a variety of call modalities, including night float, evening call, and overnight call.

OBJECTIVES: To explore the impact that call modalities have on medical students, and elucidate preferences.

DESIGN/METHODS: We conducted focus groups of 5-7 medical students each. Participants were asked about their experiences with various call systems during clerkship. Verbatim transcripts were analyzed independently by 2 team members using grounded-theory. All codes were further reviewed by the Principal Investigator.

RESULTS: Thirty-eight students participated in 6 focus groups. Four over-arching themes were identified as influencing call preferences: (1) Educational value, including patient volume and variety, hands-on experience, and teaching; (2) Quality of life, including fatigue/burn-out, ability to maintain a healthy lifestyle, and free time; (3) Continuity and quality of patient care; (4) Contribution to professional identity and acquisition of CanMEDS roles. Overnight call was described as a “rite of passage”, contributing to improved time management skills, a sense of collegiality, and self-perception as future physicians. With traditional call, post-call days provide opportunity to maintain well-being, although some believe 24-hour shifts impair ability to learn. Moreover, this call modality results in the lowest patient continuity of care. With regard to night float, most students appreciate focused call duties, and enjoy consistency with residents, resulting in greater bonding and teaching. However, they have difficulty adjusting to a nocturnal schedule, and lament missing daytime educational activities during call week. Evening call has the fewest patient encounters, least teaching, and worst fatigue and burn-out. Nonetheless, this call modality has the best patient continuity of care with no loss of daytime work. Students designated overnight call and night float as their preferred modalities, with evening call being unanimously rated least favourite. Students believe that specific goal-setting, and feedback from residents and staff are lacking across all call modalities.

CONCLUSION: Students emphasize educational value and quality of life as important determinants of their call experience. Interestingly, acquisition of professional attributes and continuity of care play an important role in determining call preferences. We suggest that integrating the above elements and introducing a formal “call curriculum”, may make the clerkship call experience more standardized and beneficial to medical students, facilitating their growth as medical professionals.
Long-Term Effects of Saline Boluses in Very Preterm Infants (VPI)
Authors: Aslam A , Vincer M , Allen A , Imanullah S , Connell C O’
Published: September 2022

BACKGROUND: Normal saline bolus is commonly used in clinical practice for treating hypotension in term and preterm neonates during resuscitation in early life despite the paucity of high quality evidence supporting this practice.

OBJECTIVES: To determine the effects of normal saline boluses given within seven days of birth in VPI less than 31 weeks at 18 to 36 of months corrected age.

DESIGN/METHODS: This is a retrospective population-based cohort analysis of the use of saline boluses from January 2006 to December 2010, of VPI from Halifax County. The outcomes at 18-36 months corrected age were extracted from the Perinatal Follow-Up Program (PFUP) database. This program is dedicated to the care and monitoring of infants who were VPI, very low birth weight or those who had brain injury at birth. It includes the evaluation of long-term developmental outcomes, multidisci-plinary services including rehabilitation, dietetics and social services. Primary Outcome: To assess the incidence of death, cerebral palsy, language, cognitive delay, hearing impairment requiring the amplification, or bilateral blindness at the corrected 18-36 months of VPI who did or did not receive normal saline boluses. Secondary Outcome: To assess patent ductus arteriosus(PDA), bronchopulmonary dysplasia (BPD), intraventricular hemorrhage (IVH), periventricular leucomalacia, necrotizing enterocolitis (NEC) and retinopathy of prematurity (ROP) between VPI who did or did not receive normal saline boluses. Inclusion criteria: VPI from Halifax County admitted to the NICU at the IWK Health Centre, Halifax, Nova Scotia, Canada between January 2006 to December 2010. Exclusion criteria: Infants with major congenital anomalies and who were not offered resuscitation in the delivery room and expected to die.

RESULTS: The regression analysis indicated that there was no difference in terms of death or disability between those who received saline bolus 15 (53.6%) versus those who did not receive saline boluses 45 (34.6%), [OR 2.17 (0.94, 5.05) p = 0.07]. Although univariate comparisons between the two groups showed significant differences in rates of PDA, severe IVH, NEC, cystic PVL, BPD and ROP, but after controlling for the influences of birth weight, APGAR score at 1 minute, admission BP and hemoglobin, bolus treatment was not significantly related to any of these outcomes

CONCLUSION: In the current study no significant difference was found between the two groups in terms of long term neurodevelopmental outcomes and short term outcomes were significantly different only in univari-ate comparisons. Given the limitations of this retrospective study, a randomized controlled trial to evaluate the effects of normal saline boluses use during early life on neurodevelopment outcomes is warrented.
Antenatal, Perinatal and Neonatal Factors Associated with Periventricular White Matter Injury in Very Preterm Infants
Authors: Ghotra S , Vincer M , Allen V , Khan N , Kuhle S
Published: September 2022

BACKGROUND: Although survival outcome in preterm infants has reached nearly 90%, long-term motor and cognitive disability and cerebral palsy in survivors remain an important concern. Periventricular white matter injury (WMI) is the major form of brain injury underlying these neurological morbidities. Cystic periventricular leukomalacia (cPVL) and porencephaly contribute significantly to poor long-term neurodevelopmen-tal outcomes. Currently, there is no definitive therapy available to treat cPVL or porencephaly. The management mainly lies in identification of associated risk factors and their prevention. Most studies on risk factors of cPVL are limited in their retrospective case-control design and sample size, and have an inherent selection bias with the use of hospital-based data.

OBJECTIVES: To identify risk factors for cPVL and porencephaly in a population-based cohort of very preterm infants.

DESIGN/METHODS: A retrospective population-based cohort study was conducted at the at the IWK Health Centre, Halifax, Nova Scotia, using data derived from the provincial Perinatal Follow-Up Program (PFUP) database. The PFUP database contains patient data for all pre-term infants born at a gestational age (GA) of <31 weeks in Nova Scotia since 1993. Infants born at 22 to 30 weeks from 1993 to 2013 (21 years) were included in the study. Infants with severe congenital malformations or chromosomal anomalies or who died in the first 6 weeks of life were excluded. Information on potential risk factors (divided into 3 groups: antenatal, perinatal and neonatal) as well as the presence or absence of cPVL and porencephaly diagnosed by cranial ultrasound at 6 weeks of age were extracted. Variables with a P value of < 0.20 in the univariate analysis were entered in the multivariate model using a backwards selection procedure.

RESULTS: Of 1184 infants found eligible for the study, 87 (7.4%) had cPVL or porencephaly. Mean GA and birth weight were 27.9 weeks and 1133 g, respectively. The gestational age-adjusted prevalence of cPVL or porencephaly did not decrease over time (p=0.07). In multivariable logistic regression analysis, chorioamniotis (OR 2.2, 95% CI 1.1-4.3), antenatal steroids (OR 0.33, 95% CI 0.18-0.61), admission hypothermia (OR 1.8, 95% CI 1.1-2.9), ventilator support (OR 4.8, 95% CI 1.4-16.9), and non-coagulase negative staphylococcal (OR 2.4, 95% CI 1.2-4.9) and fungal (OR 5.2, 95% CI 1.4-18.6) infections were independently associated with cPVL or porencephaly in the final model.

CONCLUSION: This population-based cohort study has identified a number of clinically relevant factors associated with cPVL or porenceph-aly in very preterm infants. The findings have important implications in the delivery of perinatal and neonatal care to reduce the incidence of WMI and consequent, neurological morbidity.
Restructuring Care Teams Within a Neonatal Intensive Care Unit
Authors: Ward C , Chinnery H , Landry MA , OBlenes S , Kumaran K
Published: September 2022

BACKGROUND: Organizing care teams in a large neonatal intensive care unit (NICU) is a challenge. In our pod-based model, babies were assigned a care team based on acuity and bed location. They were frequently moved between teams to accommodate nursing assignments, causing an imbalance in patient census and acuity across teams. As part of a larger process improvement project, we implemented and studied an alternate model for assigning patients to a care team.

OBJECTIVES: The objective of this project was to improve consistency of patient care and to balance the workload across the three care teams in the NICU.

DESIGN/METHODS: The setting is a 69 bed tertiary teaching NICU with approximately 1300 admissions a year. Three clinical teams share day to day assignment of a combination of these level III and level II pods. A multidisciplinary subgroup conducted a two hour Kaizen (brain storming) event with a larger group of stake-holders during which the decision was made to assign babies to a care team based on current workload of each team. The care teams follow each patient from admission to discharge, regardless of the baby’s location within the unit instead of moving babies between teams. Education communication, feedback strategies regarding the process change were formulated and executed by the sub-group. The new method was piloted for a period of three months. Objective data was collected regarding patient movement, patient acuity, census balance, and rounds time. Qualitative data was collected through staff and family surveys. ignments, causing an imbalance in patient census and acuity across teams. As part of a larger process improvement project, we implemented and studied an alternate model for assigning patients to a care team.

RESULTS: Forty percent of babies admitted to the NICU crossed care teams during their stay prior to the process change while 0.3% changed teams after the change. The number of moves per patient decreased from 1.4 to 1.27. The variability in both census and acuity was diminished following implementation of the changes. The daily average number of man-hours to complete daily rounds decreased from 47.5 before the change to 40.5 after the change. There was a 35% response rate to the staff survey with an overall positive response to the changes with regards to improving the patient and family experience. The family satisfaction survey showed a trend toward increased satisfaction following the change.

CONCLUSION: Process improvement methods can be used to successfully change how care teams are structured in a tertiary NICU.
Current Practices and Use of Simulation in Neonatal Resuscitation Program Courses Across Canada
Authors: McMullen J , Kalaniti K , Campbell D
Published: September 2022

BACKGROUND: Simulation is an effective tool in medical education. The extent and manner in which simulation is used within Neonatal Resuscitation Program (NRP) courses across Canada is currently unknown. In order to improve NRP education, current practices must be better understood.

OBJECTIVES: To characterize current practices and use of simulation in NRP courses across Canada.

DESIGN/METHODS: A REDCap survey, consisting of questions about instructor demographics, practices in NRP instruction and use of simulation, was developed and distributed to all NRP instructors across Canada. Simple statistics were used to tabulate responses and the chi-squared test was used to assess differences in simulation use between different types of instructors.

RESULTS: Five hundred sixty nine of 1390 (40.9%) NRP instructors completed the survey. Participants included 88 (15.5%) physicians, 74 (13.0%) respiratory therapists, 345 (60.6%) registered nurses and 28 (4.9%) nurse practitioners. Two hundred fifty eight (45.4%) worked in institutions providing Level III care. Overall, 560 (98.4%) respondents used simulation, of which only 176 (31.4%) reported using high-technology simulation. Only 180 (31.6%) instructors who used simulation reported having received formal training in high-technology simulation. When asked about the role of simulation in NRP instruction, 545 (95.8%) agreed or strongly agreed that simulation is a valuable educational tool in NRP instruction, but only 219 (39.1%) felt comfortable using high-technology simulation. There was no difference in use of high-technology simulation between physician and non-physician instructors (I2 0.90, p=0.34). Of the instructors who used high-technology simulation, 160 (90.9%) and 134 (76.1%) had learners and instructors, respectively, from multiple healthcare disciplines present in some or all sessions. There was a non-significant trend towards higher use of interprofessional learners among physician instructors (I2 3.8, p=0.052). An impressive 554 (98.9%) debriefed after some or all simulation sessions, with only 295 (51.8%) instructors having received formal training in debriefing techniques.

CONCLUSION: Almost all NRP instructors use simulation and feel that it is valuable, though few have received formal training and feel comfortable using high-technology simulation. Most simulation use is low-technology, in keeping with the Canadian Paediatric Society (CPS) recommendations, though the optimal methods of use of simulation in NRP instruction are not known. The majority of instructors debrief with learners, as recommended by the CPS, though only half have had training in debriefing. The results of this study support further investigation into the optimal type of simulation in NRP teaching and more formal education in simulation and debriefing for NRP instructors.
Changes to Antibiotic Use After the Introduction of an Antimicrobial Stewardship Program in a Neonatal Intensive Care Unit
Authors: Leifso K , Dow K , McKnight S , Sheth P , Tomalty L
Published: September 2022

BACKGROUND: Inappropriate or prolonged antibiotic use in neonatal intensive care units can lead to the emergence of antibiotic resistant bacteria as well as complications such as invasive candidiasis and necrotizing enterocolitis. An antimicrobial stewardship program (ASP) was introduced in our level II/III neonatal intensive care unit (NICU) with the goal of optimizing patient safety and outcomes with respect to antimicrobial use as well as to reduce the risk of infection or colonization by antimicrobial resistant organisms (AROs). The ASP included a pediatric infectious diseases physician, a neonatologist or delegate, a microbiologist and a pharmacist who met twice weekly to review all admitted neonates who had been receiving antibiotics for more than 24 hours.

OBJECTIVES: In order to evaluate the effectiveness of ASP interventions, we conducted a retrospective review of antibiotic use in the NICU comparing the two years before the ASP and the first year of the ASP operation.

DESIGN/METHODS: Antimicrobial use from the two years prior and one year following the ASP start date of December 1st, 2014 was compared. All neonates who received antimicrobials between the dates of December 1st, 2012 and November 30th, 2015 were included in the review. Antifungal and antiviral use were excluded. Antibiotic start and stop dates were collected from the patient charts. After the start of the ASP, antibiotic start and stop dates were obtained from the computerized pharmacy database. Overall days of therapy (DOTs) and antibiotic-specific DOTs, were calculated per 1000 patient-days.

RESULTS: In the first year, 109 reviews were performed on 70 neonates. The pediatric ID service was already following 25 babies leaving 84 reviews. Changes were recommended in 43 (51%) instances. Discontinuation of antibiotics was recommended in 26 (60%), reduced length of therapy or decreased spectrum of antibiotic in 10 (24%), and ID consultation in 9 (21%). Overall and selected antibiotic exposure in the NICU is presented in Table 1 (See page e79).

CONCLUSION: Introduction of an ASP reduced the overall exposure to antimicrobials in the NICU. Marked reductions in third-generation cepha-losporin and vancomycin use were observed in the first year of the ASP.
Integrated Neonatal Support with Placental Transfusion and Resuscitation (Inspire): A Feasibility Study
Authors: Irvine L , Thomas S , Mehrem A Abou , Singhal N , Kowal D , Soraisham A , Cooper S , Stritzke A , Murthy P
Published: September 2022

BACKGROUND: Compromised neonates do not receive placental transfusion (PT), but receive immediate cord clamping to facilitate resuscitation. Animal studies suggest possible benefit of resuscitation during PT.

OBJECTIVES: To study the feasibility of initiating resuscitative care during PT for 90s in preterm infants.

DESIGN/METHODS: We designed a mobile, battery powered resuscitation platform (iNSPiRe) that contains a scale, warm gel mattress, oxygen and air tanks, blender, T piece resuscitator, pulse oximeter (PO), and suction device (Fig. 1). Resuscitative care included initial steps, and respiratory support at 30s following Neonatal Resuscitation Program guidelines. Thermoregulation was maintained using a hat, warmed blankets, and gel mattress. Heart rate was auscultated at 30, 60 and 90s. PO was placed on the right wrist/hand. The cord was clamped at 90s. The baby and platform were mobilized from mother’s bedside to a radiant warmer by one provider, while another provider maintained respiratory support. Once on the warmer, axillary temperature (AT) was measured. Resuscitation interventions and management during first 24 hours were recorded.

RESULTS: Seven infants born vaginally, median (range) gestational age (GA) was 30 weeks (28 to 36) and birth weight 1500g (1270 to 2650), were managed using iNSPiRe. Table 1 shows time (T) to initiate interventions, cord pH and Apgar scores. Five infants received continuous positive airway pressure (CPAP) and one received positive pressure ventilation; none had hypotension, pneumothorax, or received surfactant. No incidence of intraventricular hemorrhage.

CONCLUSION: It is feasible to commence resuscitative care during PT in infants ≥30 weeks' GA for 90s. Further research is needed to assess the feasibility in smaller and sicker preterm infants.
Parental Satisfaction Towards Autism Spectrum Disorder Diagnostic Assessment Process for Children 12-39 Months.
Authors: Lemay JF , Langenberger S
Published: September 2022

BACKGROUND: To address lengthy delays in accessing diagnostic assessment for Autism Spectrum Disorder (ASD), our ASD services underwent a review of the service model in 2013-2014. In addition to establishing a formal ASD Diagnostic Clinic, the diagnostic evaluation process for children 12-39 months was re-designed. A major implemented change as part of our diagnostic process was the Pre- and Post-diagnosis parent information sessions.

OBJECTIVES: To assess the satisfaction level for parents of children being evaluated through our new ASD diagnostic process for children 12-39 months.

DESIGN/METHODS: This evaluation was done through two different surveys: 1) a validated, standardized telephone survey (average 15 minutes) was administered by an experienced nurse to parents whose child was diagnosed with ASD (January 2014-June 2015) based on the new ASD diagnostic process. Parents were asked to retrospectively evaluate their experience undergoing the new diagnostic assessment process; 2) a subgroup of parents completed a written survey to evaluate the Pre- and Post-diagnosis parent information sessions (of note: survey was given at the end of these educational sessions).

RESULTS: 1) Telephone questionnaire: a total of 68/96 parents were surveyed (71% overall response rate; >90% mothers). Percentage of strongly agree/agree answers were obtained to these statements: a) better awareness of your child’s needs: 78%; b) receiving useful ASD information and educational materials: 90% c) overall process met needs: 77%; d) overall experience: 80%; e) parents having early intervention support since the ASD diagnostic assessment given to their child: 91%; 2) In regards to the educational sessions (Pre-diagnosis ([n=44] & Post ASD Diagnosis [n=33]), the responses to questions on the delivery, content and materials presented revealed >90% level of satisfaction. Challenges to attending theses educational sessions were less than we anticipated.

CONCLUSION: The level of satisfaction to our ‘new’ ASD diagnostic process for children 12-39 months, as reported by parents, was very good. Parents felt the Pre- & Post-educational sessions were positive and valuable. This Quality Improvement initiative, redesigning the ASD diagnostic assessment process, has been validated by families.