bluuebunny/crossref_metadata_2025 huggingface dataset:
Diastolic dysfunction and mortality in 436 360 men and women: the National Echo Database Australia (NEDA)
Authors: Playford David , Strange Geoff , Celermajer David S , Evans Geoffrey , Scalia Gregory M , Stewart Simon , Prior David ,   the NEDA Investigators
Published: August 2020

Aims 

To examine the characteristics/prognostic impact of diastolic dysfunction (DD) according to 2016 American Society of Echocardiography (ASE) and European Society of Cardiovascular Imaging (ESCVI) guidelines, and individual parameters of DD.

Methods and results 

Data were derived from a large multicentre mortality-linked echocardiographic registry comprising 436 360 adults with ≥1 diastolic function measurement linked to 100 597 deaths during 2.2 million person-years follow-up. ASE/European Association of Cardiovascular Imaging (EACVI) algorithms could be applied in 392 009 (89.8%) cases; comprising 11.4% of cases with ‘reduced’ left ventricular ejection fraction (LVEF < 50%) and 88.6% with ‘preserved’ LVEF (≥50%). Diastolic function was indeterminate in 21.5% and 62.2% of ‘preserved’ and ‘reduced’ LVEF cases, respectively. Among preserved LVEF cases, the risk of adjusted 5-year cardiovascular-related mortality was elevated in both DD [odds ratio (OR) 1.31, 95% confidence interval (CI) 1.22–1.42; P < 0.001] and indeterminate status cases (OR 1.11, 95% CI 1.04–1.18; P < 0.001) vs. no DD. Among impaired LVEF cases, the equivalent risk of cardiovascular-related mortality was 1.51 (95% CI 1.15–1.98, P < 0.001) for increased filling pressure vs. 1.25 (95% CI 0.96–1.64, P = 0.06) for indeterminate status. Mitral E velocity, septal e’ velocity, E:e’ ratio, and LAVi all correlated with mortality. On adjusted basis, pivot-points of increased risk for cardiovascular-related mortality occurred at 90 cm/s for E wave velocity, 9 cm/s for septal e’ velocity, an E:e’ ratio of 9, and an LAVi of 32 mL/m2.

Conclusion 

ASE/EACVI-classified DD is correlated with increased mortality. However, many cases remain ‘indeterminate’. Importantly, when analysed individually, mitral E velocity, septal e’ velocity, E:e’ ratio, and LAVi revealed clear pivot-points of increased risk of cardiovascular-related mortality.
Pulmonary valve reconstruction using Ozaki’s technique for infective endocarditis
Authors: Yepez Cristian , Ríos Josias
Published: August 2020

Simultaneous pulmonary and aortic endocarditis is extremely rare, and there is no consensus on its surgical management. Here, we report a case of infective endocarditis of pulmonary and aortic valves complicated by severe pulmonary regurgitation due to complete damage of valve cusps. We performed pulmonary valve reconstruction using autologous pericardium using Ozaki’s technique, with excellent outcomes.
Y Haplogroup Diversity of the Dominican Republic: Reconstructing the Effect of the European Colonization and the Trans-Atlantic Slave Trades
Authors: D’Atanasio Eugenia , Trionfetti Flavia , Bonito Maria , Sellitto Daniele , Coppa Alfredo , Berti Andrea , Trombetta Beniamino , Cruciani Fulvio
Published: August 2020

The Dominican Republic is one of the two countries on the Hispaniola island, which is part of the Antilles. Hispaniola was affected by the European colonization and massive deportation of African slaves since the XVI century and these events heavily shaped the genetic composition of the present-day population. To shed light about the effect of the European rules, we analyzed 92 single nucleotide polymorphisms on the Y chromosome in 182 Dominican individuals from three different locations. The Dominican Y haplogroup composition was characterized by an excess of northern African/European lineages (59%), followed by the African clades (38%), whereas the Native-American lineages were rare (3%). The comparison with the mitochondrial DNA variability, dominated by African clades, revealed a sex-biased admixture pattern, in line with the colonial society dominated by European men. When other Caribbean and non-Caribbean former colonies were also considered, we noted a difference between territories under a Spanish rule (like the Dominican Republic) and British/French rule, with the former characterized by an excess of European Y lineages reflecting the more permissive Iberian legislation about mixed people and slavery. Finally, we analyzed the distribution in Africa of the Dominican lineages with a putative African origin, mainly focusing on central and western Africa, which were the main sources of African slaves. We found that most (83%) of the African lineages observed in Santo Domingo have a central African ancestry, suggesting that most of the slaves were deported from regions.
The Framing of “Alzheimer’s Disease”: Differences Between Scientific and Lay Literature and Their Ethical Implications
Authors: Smedinga Marthe , Bunnik Eline M , Richard Edo , Schermer Maartje H N
Published: August 2020

Background and Objectives

The meaning of Alzheimer’s disease (AD) is changing in research. It now refers to a pathophysiological process, regardless of whether clinical symptoms are present. In the lay literature, on the other hand, AD is understood as a form of dementia. This raises the question of whether researchers and the lay audience are still talking about the same thing. If not, how will these different understandings of AD shape perspectives on (societal) needs for people with AD?

Research Design and Methods

We use framing analysis to retrieve the understandings of the term AD that are upheld in the research literature and in national Dutch newspaper articles. We make explicit how the framings of AD steer our normative attitudes toward the disease.

Results

In the analyzed research articles, AD is framed as a pathological cascade, reflected by biomarkers, starting in cognitively healthy people and ending, inevitably, in dementia. In the lay literature, AD is used as a synonym for dementia, and an AD diagnosis is understood as an incentive to enjoy “the time that is left.”

Discussion and Implications

The two different uses of the term AD in research and in the lay literature may result in misunderstandings, especially those research framings that falsely imply that people with AD biomarkers will inevitably develop dementia. Adoption of the research understanding of AD in clinical practice will have normative implications for our view on priority setting in health care. For example, it legitimizes biomarker testing in people without dementia as improving “diagnostic” certainty.
Time Effects of Informal Caregiving on Cognitive Function and Well-Being: Evidence From ELSA
Authors: Yuan Jing , Grühn Daniel
Published: August 2020

Background and Objectives

As informal caregiving becomes prevalent, its consequences for caregivers’ cognitive and socioemotional functioning gain more importance for society. There are inconsistent findings regarding the direction of the impact of caregiving—whether caregiving maintains or compromises functioning—and the impact of time—whether the effects accumulate or are stable. In this study, we elucidated 3 time effects of caregiving—concurrent, cumulative, and lagged effects—on cognitive and socioemotional functioning.

Research Design and Methods

We used data from Wave 1 (2002–2003) to Wave 8 (2016–2017) in the English Longitudinal Study of Ageing (ELSA) and latent growth curve models with the time-varying predictor to investigate 3 time effects of caregiving on cognitive function (memory and executive function) and well-being (life satisfaction and quality of life).

Results

Over and beyond age effects, current caregiving (concurrent effect) was related to worse well-being and better delayed recall. Little robust cumulative effect was found on cognition and well-being. In addition, there were significant and differential lagged effects of caregiving after controlling for concurrent and cumulative effects; that is, caregiving was related to worse well-being and better memory functioning 2–4 years later.

Discussion and Implications

The differential concurrent and lagged effects of caregiving on cognitive and socioemotional functioning suggest separate mechanisms for different domains of functioning. The nonsignificant cumulative effects but significant lagged effects imply that even one-time caregiving has long-term (2–4 years) consequences for the caregiver’s future functioning, and the mechanism of long-term caregiving effects may be more qualitative than quantitative.
Body Mass Index Does Not Impact Clinical Efficacy of Ustekinumab in Crohn’s Disease: A Post Hoc Analysis of the IM-UNITI Trial
Authors: Wong Emily C L , Marshall John K , Reinisch Walter , Narula Neeraj
Published: August 2020

Background

This post hoc analysis aimed to evaluate the impact of BMI on the efficacy of ustekinumab in the IM-UNITI study.

Methods

The relationship between body mass index (BMI) and efficacy of ustekinumab was evaluated using data from a 44-week maintenance study of ustekinumab in Crohn’s disease (IM-UNITI, NCT01369355, YODA #2019–4105). The primary endpoints of interest were clinical remission (CR), defined as Crohn’s disease activity index <150 and corticosteroid-free CR at week 44. Patients were stratified into the following subgroups according to their BMI at study entry: underweight <18.5 kg/m2, normal 18.5 to 25 kg/m2, overweight 25 to <30 kg/m2, and obese ≥30 kg/m2. The χ 2 test of linear trend was conducted for comparisons of frequencies between the 3 cohorts. Multivariate regression analyses evaluated possible association between BMI and efficacy outcomes of CR and corticosteroid-free CR, with adjustment for variables found significant on univariate analyses. Results are presented as odds ratios with 95% confidence intervals. Data were analyzed using Stata/IC 15.

Results

A total of 254 patients treated with ustekinumab were included in this analysis. At week 44 of IM-UNITI, rates of CR did not differ among those whose BMI was underweight (67.9%%; 19 of 28 patients), normal (51.3%; 60 of 117), overweight (45.1%; 32 of 71), or obese (55.3%; 21 of 38; P = 0.89). Multivariate logistic analysis did not find BMI to be a significant predictor of CR when adjusted for covariates. Ustekinumab drug level at week 44 was significantly lower in obese patients (median level 2.98 mcg/mL; interquartile range [IQR], 2.86) compared with patients who were overweight (4.84 mcg/mL; IQR, 3.51; P = 0.021) or had underweight or normal BMI (4.43 mcg/m;, IQR, 2.82; P = 0.014).

Conclusions

Although BMI impacts ustekinumab drug levels, there was no impact of BMI on clinical efficacy. Further studies of the pharmacodynamic effects of ustekinumab in patients with high BMI are needed.
Innovation in IBD Care During the COVID-19 Pandemic: Results of a Cross-Sectional Survey on Patient-Reported Experience Measures
Authors: Taxonera Carlos , Alba Cristina , Olivares David , Martin María , Ventero Alejandro , Cañas Mercedes
Published: August 2020

Background

The coronavirus 2019 (COVID-19) pandemic is a clinical situation that could be used as prototype for implementation of new systems of care.

Methods

This was a single-center, cross-sectional study. We evaluated the feasibility of a strategy based on the conversion of face-to-face visits to telephone consultations to manage IBD outpatients during the COVID-19 pandemic. A 4-item telephone survey (3 closed questions and a 100-point numeric description scale) was conducted to evaluate satisfaction of patients with telephone consultations.

Results

Between March 11 and April 8, 2020, 98% of the 216 scheduled face-to-face visits could be converted to telephone consultations, and we resolved an additional 162 urgent consultations by telephone. The rate of IBD-related hospitalization and visits to the emergency department decreased by 50% and 58%, respectively, compared with rates in the same period the previous year. The 4-item survey was conducted in 171 outpatients. In closed questions, patients reported a very high degree of satisfaction with telephone consultations, with no differences between scheduled (n = 123) and urgent consultations (n = 48; P = NS). The overall satisfaction rating with the telephone consultation evaluated with the numerical description scale was 94% and 93% for scheduled and urgent consultations, respectively (P < 0.82). Less than 20% of patients would have preferred a face-to-face visit to the telephone consultation at the time.

Conclusions

A strategy based on the conversion of face-to-face visits to telephone consultations was able to guarantee a minimum standard quality of care during the COVID-19 pandemic. Patients reported a very high degree of satisfaction with telephone consultations.
90-Day Specific Readmission for Clostridium difficile Infection After Hospitalization With an Inflammatory Bowel Disease Flare: Outcomes and Risk Factors
Authors: Palacios Argueta Pedro , Salazar Miguel , Attar Bashar , Simons-Linares Roberto , Shen Bo
Published: August 2020

Background

Patients with inflammatory bowel disease (IBD) have an increased risk for Clostridium difficile infection (CDI) and carry significantly higher morbidities and mortality than those without IBD. We aimed to investigate disease-specific readmission rates and independent risk factors for CDI within 90 days of an index hospitalization for an IBD flare.

Methods

The Nationwide Readmission Database was queried for the year 2016. We collected data on hospital readmissions of 50,799 adults who were hospitalized for urgent IBD flare and discharged. The primary outcome was disease-specific readmission rate for CDI within 90 days of discharge. The secondary outcomes were readmission rate of colonoscopic procedures, morbidities (including mechanical ventilation and shock), and hospital economic burden. The risk factors for readmission were identified using Cox regression analysis.

Results

The 90-day specific readmission rate was 0.1% (N = 477). A total of 3,005 days were associated with readmission, and the total health care in-hospital economic burden of readmission was $19.1 million (in charges) and $4.79 million (in costs). Independent predictors during index admission for readmission were mechanical ventilation for >24 hours (hazard ratio [HR], 6.62, 95% confidence interval [CI], 0.80-54.57); history of previous CDI (HR, 5.48; 95% CI, 3.66-8.19); HIV-positive status (HR, 4.60; 95% CI, 1.03-20.50); alcohol abuse disorders (HR, 2.06; 95% CI, 1.15-3.70); Parkinson’s disease (HR, 4.68; 95% CI, 1.65-13.31); index admission for noncomplicated ulcerative colitis (HR, 4.72; 95% CI, 2.99-7.45]-), complicated ulcerative colitis (HR, 4.49; 95% CI, 2.80- 7.18), or noncomplicated Crohn disease (HR, 2.54; 95% CI, 2.80-4.04); and hospital length of stay (HR, 1.01; 95% CI, 1.01-1.02).

Conclusions

The 90-day CDI-specific readmission rate after the index admission of IBD flares was 0.1%. We found risk factors for CDI-associated readmissions such as history of Parkinson’s disease, prior CDI, HIV-positive status, and alcohol abuse disorder. Finally, our study also revealed a high health care cost, charges, and burden.
The Wrong Cure: Financial Incentives for Unimpressive New Antibiotics
Authors: Sinha Michael S , Powers John H , Kesselheim Aaron S
Published: August 2020

Though antimicrobial resistance is a public health concern, the basis of approval for many new antibiotics does not distinguish them from older products. We suggest a more tailored incentive structure for antibiotic development, focused on clinical benefit and patient outcomes.
A Critical Review on the Use of Race in Understanding Racial Disparities in Preeclampsia
Authors: Fasanya Henrietta O , Hsiao Chu J , Armstrong-Sylvester Kendra R , Beal Stacy G
Published: August 2020

Background

Preeclampsia is a significant cause of maternal morbidity and mortality, affecting up to 8% of pregnancies globally. Although the precise etiology is still under study, the literature suggests that vascular changes reduce placental perfusion and affect the remodeling of spiral arteries to create the hallmark feature of preeclampsia: elevated blood pressure. Screening for preeclampsia is currently recommended for all pregnant women, particularly if risk factors exist. A noted risk factor codified in guidelines is “African-American race.”

Content

We summarize the racial disparities in preeclampsia incidence, morbidity, and mortality. We consider the limitations of using race to understand disparities by also examining multiethnic, immigration, and international studies. We then critically evaluate laboratory analytes associated with racial disparities of preeclampsia and explore other mechanisms of action, such as socioeconomic status, stress, and access to care.

Black and African-American women are consistently at higher risk of preeclampsia incidence, morbidity, and mortality than their white counterparts. Asian women are consistently at lower risk of preeclampsia, whereas the association for Hispanic women remains unclear. When these broad racial categories are subdivided by geographic or cultural origin, preeclampsia disparities within racial groups are identified. The limited literature suggests that sub-Saharan African immigrants tend to have a higher risk of preeclampsia than US-born white populations but a lower risk than US-born Black women. Existing studies seeking to identify racial differences in analytes have limited research designs and tend to operationalize race as a proxy for biologically inherent (i.e., genetic) differences between races despite a plethora of other possible explanatory mechanisms.
Boutiques and Prêt-à-porter in Santiago de Chile: A Formula for Women’s Modernity (1967–1973)
Authors: Miranda Vidal Josefina , García Macarena , Álvarez Caselli Pedro
Published: August 2020

In the second half of the 1960s, prêt-à-porter (ready-to-wear) fashion was established in Chile. As an alternative to haute couture (high fashion), prêt-à-porter brought an eagerness for modernisation that was reflected in the setting up of a network of women-led boutiques, which developed strongly between 1967 and 1973. This article first examines the precedents that allowed for the creation of a ‘local fashion system’ that promoted collective work around trades such as knitting and dressmaking. It also analyses the arrangement of a circuit of boutiques in the comuna of Providencia, a strategic sector of Santiago de Chile (the capital city) that fostered the dynamics of social gathering. Later, the article describes the profile of the designer-entrepreneurs whose work was attuned to a female consumer segment that aimed to access a new formula of the modernising bourgeoisie. It also reassesses the rise of a movement called Moda Autóctona, which distanced itself from European fashion and was supported by the government during the socialist regime of Salvador Allende. Lastly, it tackles the eventual dismantling of this network of women’s fashion stores as a result of the installation of a military dictatorship in Chile.
Uncertainty quantification of bioassay functions for the internal dosimetry of radioiodine
Authors: Kwon Tae-Eun , Chung Yoonsun , Yoo Jaeryong , Ha Wi-Ho , Cho Minsu
Published: August 2020

Bioassay functions, which are provided by the International Commission on Radiological Protection, are used to estimate the intake activity of radionuclides; however, they include considerable uncertainties in terms of the internal dosimetry for a particular individual. During a practical internal dose assessment, the uncertainty in the bioassay function is generally not introduced because of the difficulty in quantification. Therefore, to clarify the existence of uncertainty in the bioassay function and provide dosimetrists with an insight into this uncertainty, this study attempted to quantify the uncertainty in the thyroid retention function used for radioiodine exposure. The uncertainty was quantified using a probabilistic estimation of the thyroid retention function through the propagation of the distribution of biokinetic parameters by the Monte Carlo simulation technique. The uncertainties in the thyroid retention function, expressed in terms of the scattering factor, were in the ranges of 1.55–1.60 and 1.40–1.50 for within 24 h and after 24 h, respectively. In addition, the thyroid retention function within 24 h was compared with actual measurement data to confirm the uncertainty due to the use of first-order kinetics in the biokinetic model calculation. Significantly higher thyroid uptakes (by a factor of 1.9) were observed in the actual measurements. This study indicates that consideration of the uncertainty in the thyroid retention function can avoid a significant over- and under-estimation of the internal dose, particularly when a high dose is predicted.
A giant radio bridge connecting two clusters in Abell 1758
Authors: Botteon A , van Weeren R J , Brunetti G , de Gasperin F , Intema H T , Osinga E , Gennaro G Di , Shimwell T W , Bonafede A , Brüggen M , Cassano R , Cuciti V , Dallacasa D , Gastaldello F , Mandal S , Rossetti M , Röttgering H J A
Published: August 2020

Collisions between galaxy clusters dissipate enormous amounts of energy in the intra-cluster medium (ICM) through turbulence and shocks. In the process, Mpc-scale diffuse synchrotron emission in form of radio halos and relics can form. However, little is known about the very early phase of the collision. We used deep radio observations from 53 MHz to 1.5 GHz to study the pre-merging galaxy clusters A1758N and A1758S that are ∼2 Mpc apart. We confirm the presence of a giant bridge of radio emission connecting the two systems that was reported only tentatively in our earlier work. This is the second large-scale radio bridge observed to date in a cluster pair. The bridge is clearly visible in the LOFAR image at 144 MHz and tentatively detected at 53 MHz. Its mean radio emissivity is more than one order of magnitude lower than that of the radio halos in A1758N and A1758S. Interestingly, the radio and X-ray emissions of the bridge are correlated. Our results indicate that non-thermal phenomena in the ICM can be generated also in the region of compressed gas in-between infalling systems.
Ontogenesis of the digestive gland through the planktotrophic stages of Strombus gigas
Authors: Aldana Aranda Dalila , Enríquez Díaz Martha , Gros Olivier
Published: August 2020

The queen conch, Strombus gigas (Linnaeus, 1758), is a marine mollusc of ecological and economic importance in the Caribbean. Its populations are declining due to overexploitation. We describe ontogenesis of the digestive gland in S. gigas during the larval stages. Larvae were studied over a period of 42 d in laboratory culture, from eggs to crawling stage. Experiments were conducted at 28 ± 1°C. Veligers were reared at a density of 100 larvae l−1 in 10-l containers. Larvae were fed with the microalgae Nannochloropsis oculata at a concentration of 1,000 cells l−1. In this study, we analysed ultrastructural ontogenesis of the digestive gland in strombid larvae using light and electron microscopy. Examination for Coccidia (Apicomplexa) symbionts in the digestive gland was done by viewing sections with light and scanning electron microscopes at different larval development stages during a 42-d period. In early veligers (9 d after hatching), only digestive cells were observed in the digestive gland. By the late veliger stages (17 d old), both digestive and crypt cells were apparent in the digestive gland. Within crypt cells, spherocrystals were detected and the presence of Ca, Cl, Cu, P and Zn was identified by energy-dispersive X-ray spectroscopy. In late pediveligers (35 d old), the digestive gland still exhibited only digestive and crypt cells. Vacuolated cells (i.e. harbour the coccidian symbionts in adults) were only observed in newly settled juveniles (42 d old) and were devoid of apicomplexan structures. While coccidian symbionts were found in the digestive gland of adult S. gigas, they were not observed in the digestive gland of S. gigas larvae from hatching to settlement under laboratory conditions. This suggests that this symbiont is not vertically transmitted to new host generations in this marine gastropod species.
Feeding and digestion periodicity of Manila clam Ruditapes philippinarum in natural intertidal and subtidal zones estimated from the morphological condition of the crystalline style
Authors: Houki Shouji , Kawamura Tomohiko
Published: August 2020

Feeding periodicities and rhythms of suspension-feeding bivalves in coastal waters are closely related to diel and tidal cyclic environmental changes, such as food availability and predation risk. Although such feeding periodicities of bivalves are important for understanding how their feeding strategies adapt to localized habitats, the feeding periodicity in bivalves in the field remains to be clarified, especially in infaunal species. The present study focused on the morphological condition of the crystalline style as an indicator of the feeding activity of the infaunal bivalve Manila clam, Ruditapes philippinarum, and estimated their feeding periodicity in the field. First, the effects of feeding (siphon-extending) behaviour, food and the light/dark cycle on the condition of the crystalline style (defined based on its morphology and hardness) were investigated in the laboratory. Results of the ordered logistic models and model selection showed that clams extending their siphons kept their crystalline styles hard. Furthermore, the effects of the light/dark cycle and tidal phase on the condition of the crystalline style were investigated in natural intertidal and subtidal zones and assessed using the results of the ordered logistic models. In the intertidal zone, the effect of the tidal phase was significant, whereas the effect of the light/dark cycle was not, and feeding was estimated to be active at ebb and flood tides, when the density of food particles was likely to be high. On the other hand, in the subtidal zone, the results of the model selection were not clear because of significant effects of interactions between the light/dark cycle and tidal phase. However, when the interactions were removed from the models, the effect of the light/dark cycle was significant, and feeding was estimated to be active at night when the predation risk from visual predators would be relatively low. These results confirm that R. philippinarum possesses behavioural plasticity in feeding periodicity, which is adaptable to both intertidal and subtidal zones.
5 Close to Home: Implementation of a transfer process for paediatric inpatients from tertiary to community care
Authors: Gamulka Beth , Abreo Kathleen , Lee Frances
Published: August 2020

Background

Patients presenting to the emergency department who require inpatient care are either admitted to our tertiary care inpatient units or transferred directly to a community hospital. When patients appropriate for community care cannot be transferred due to a lack of community beds and instead remain in a tertiary care bed, there are palpable downstream effects on patient flow. A pre-study audit confirmed that, once admitted, transfers from the inpatient unit to a community bed are rare. This project aimed to improve access to tertiary care beds by increasing inpatient transfers to community hospitals.

Objectives

The project aimed to transfer 25% of all eligible patients from the Paediatric Medicine inpatient units to community hospitals over a 4-month period by identifying eligible patients and streamlining the transfer process.

Design/Methods

An Ishikawa diagram with input from inpatient physicians and nurses and community hospital colleagues identified 4 modifiable barriers. A process map was created along with a simplified transfer process. Medical teams and nurse leaders were provided with the charts of contact numbers, geographic locations and levels of care for community hospitals. Intake nurses tracked eligible patients. Encrypted text messages were sent to inpatient physicians on their mobile devices every morning reminding them to assess specific patients for transfer. The outcomes of all identified patients including process and balancing measures were tracked.

Results

Multiple PDSA cycles focused on improving the success of identifying eligible patients at multiple points in the process. The study’s outcome measure was the rate of successful inpatient transfers for all eligible patients. From November 2018 to March 2019, 120 patients were identified as eligible for transfer at the time of admission: 45 (37.5%) were discharged within 24 hours, 42 (35%) were not considered clinically appropriate for transfer by the attending physician and 33 were considered appropriate for transfer. Twenty-four were approached for transfer (72.7%); 9 were not approached for non-clinical reasons. Six (18.2%) refused transfer and 10 (30%) were successfully transferred. These rates were sustained over the study period.

Conclusion

A streamlined transfer process can improve patient flow, optimize utilization of tertiary care beds and provide care closer to home. A more robust method of tracking patients that could flag patients and send physicians electronic reminders is needed. Most importantly, optimal use of tertiary care beds requires a culture shift to ensure every patient is considered for transfer to the community when medically appropriate.
20 Evaluation of Compliance with the 2017 Canadian Pediatric Society (CPS) Position Statement for the Management of Newborns at Risk for Early-Onset Sepsis (EOS): A Retrospective Cohort Study
Authors: Simeonova Marina , Piszczek Jolanta , Hoi Sannifer , Harder Curtis , Pelligra Gustavo
Published: August 2020

Background

Due to the high mortality and non-specific clinical presentation, clinicians often empirically treat newborns at risk of early-onset sepsis (EOS). Recently, the Canadian Pediatric Society (CPS) published updated recommendations that promote a more judicious approach to EOS management.

Objectives

To examine the compliance with the CPS position statement at a tertiary perinatal site.

Design/Methods

A retrospective chart review was conducted between Jan 1 – Jun 30, 2018. Newborns were categorized into 5 groups, depending on the number of EOS risk factors. Management strategies were assessed against the CPS recommendations to establish the rate of non-compliance. The reason for non-compliance, readmission rate and rate of culture-positive EOS were also examined. Results were expressed using descriptive statistics. A Chi-squared test was conducted to assess the association between the readmission rate and initial management.

Results

The total non-compliance rate was 47%. This was mostly due to inappropriate investigations in lower EOS risk groups [3 (71%) and 4 (94%)] and withholding antibiotics in groups with more risk factors [1 (43%) and 2 (67%)]. The rate of readmission for a septic work-up was low (<2%), and no newborns had culture-positive EOS. There was no significant association between the readmission rate and initial management (p=0.13).

Conclusion

Although the rate of non-compliance to the 2017 CPS recommendations was high, no neonates had culture-positive EOS, suggesting that our management strategies may be too aggressive. An initial observational period for newborns at lower EOS risk (groups 3 and 4) may warrant consideration for future quality improvement initiatives.
31 Strengthening care for infants with medical complexity during the transition from the neonatal intensive care unit to the community
Authors: Kieran Emily , Dyck Chan Laura , Shivananda Sandesh
Published: August 2020

Background

With advances in technology and innovative medical treatments, infants who previously would have died in early infancy are living longer. These infants have significant needs in the medical system and pose challenges in coordinating care from multiple providers, especially after discharge from NICU.

Objectives

To engage neonatal-to-early-childhood care-transition stakeholders in implementing system-level change to champion the successful transition of infants with medical complexity into early childhood. We believe this engagement activity will spark action amongst stakeholders to adopt best practices leading to improvements in care for this vulnerable patient population.

Design/Methods

We explored four key care transition related questions:

We organized journey mapping and focus groups with NICU alumni families whose children have medical complexity. We conducted a literature review to identify evidence-based interventions. We compiled this information to create evidence briefs that were presented to an interprofessional group of senior stakeholders using the deliberative dialogue approach. Following presentation of the evidence briefs surveys were administered to measure stakeholder intention to act on solutions presented.

Results

Twenty-five opportunities for improving transitions between hospital and community care teams were identified through engagement with families and project team members (graphic A). These opportunities focused on facilitating clinical navigation, navigating community services, and improving parental mental health. Forty-two stakeholders representing a children’s and women’s hospital, families, community care providers, and provincial bodies were engaged in this project.

A rapid review of the literature was carried out using multiple databases searches to ensure comprehensiveness and flexible search strategies to ensure literature was found for all issues. This included a broader search of NICU discharges and nine targeted searches with medical complexity populations. Proposed solutions from stakeholders were further validated through comparisons with the literature and ultimately thirty-five papers were included in the evidence briefs.

Specific care interventions were recommended to key healthcare decision makers, such as providing post-discharge care coordination in a specialized complex care clinic, implementing patient-oriented discharge summaries, and facilitating access to mental health resources.

Using a seven point Likert scale the majority of stakeholders agreed that both the evidence briefs and deliberative dialogues were very successful in achieving their aim. Stakeholder intention to act on solutions presented in evidence briefs and deliberative dialogues were rated as very likely.

Conclusion
35 DUNN method versus weight based formulae to estimate umbilical arterial and venous catheters position
Authors: Correa Salustiano Maria Helena , Asselin Sarah , Olivier François , Patel Sharina , Beltempo Marc
Published: August 2020

Background

Umbilical arterial catheters (UAC) and umbilical venous catheters (UVC) are frequently used in infants admitted to neonatal intensive care units (NICU). Dunn method (DM) was used in our NICU to calculate length of insertion of UAC/UVC until July 2018, before the adoption of the weight-based formulae (WBF).

Objectives

Our primary objective was to compare both methods in regards to correct position of UAC/UVC on first attempt. As a secondary objective we assessed the correlation between the tip position of catheters in anteroposterior radiographies (APR) and lateral radiographies (LatR).

Design/Methods

This is a retrospective cohort study of infants with UAC/UVC inserted in the NICU from 2017-2019. Charts were reviewed for demographic data and catheters position in APR and LatR. The position was considered appropriate if the tip was between thoracic vertebral level (Th)6 and Th9 on APR for UAC and at Th8-Th9 on APR for UVC. Length of insertion of catheters was calculated via DM in one group and WBF in the other. Secondarily, we compared position of catheters on APR and LatR. For statistical analysis we used t student test for continuous data, Chi square test for categorical data and Pearson r for coefficient of correlation(r).

Results

Among 462 infants with UAC/UVC placed, demographic characteristics in both groups were similar (Table 1).

There was a good correlation between APR and LatR for the assessment of UVC and UAC position.

Appropriate position on first attempt for UAC was 60% (49/82) with Dunn method and 66% (74/112) with WBF (p=0.67).

Appropriate position on first attempt in UVC insertion beyond liver was 36% (46/127) using Dunn method and 43% (67/157) with WBF (p=0.47).

Rate of low positioned UVC was significantly lower using WBF compared to Dunn method: 3%(5/157) vs 9% (11/127), (p=0.04).

Position of catheters on APR and LatR were well correlated for UVC (n=146, r=0.87, p<0.001) and UAC (n=62, r=0.82, p<0.001).

Conclusion

No difference was observed for appropriate position of UAC and UVC on first attempt using DM versus WBF.

There was significantly less low positioned UVCs with WBF.
36 Contrast Enhanced Radiography for Peripherally Inserted Central Venous Catheter Tip localization- Is it really needed for all infants?
Authors: Jim Jose Mary , Soraisham Amuchou
Published: August 2020

Background

Contrast enhanced radiography (CER) is considered one of the best available methods for localizing the tip of a peripherally inserted central venous catheters (PICC) in neonates, which was the standard practice at our NICU. It was observed that multiple catheter readjustments and radio-graphs were required due to contrast jet appearing radio-graphically as a distal extension of the catheter creating a false impression of deep location of the PICC tip. This raised the question of whether we need to use contrast routinely for all infants or can we selectively use contrast when needed.

Objectives

The intention of this quality improvement project was to adopt the use of plain radiography (PR) as the first modality for PICC tip localization and use CER only if localization was unsuccessful in the first instance. The objective was to examine the effect of this change of clinical practice on the:

a)

number of radio-graphs taken for PICC insertions b) the frequency of intravenous contrast use in PICC insertion.

Design/Methods

This was a QI initiative conducted over a 7 month period. After educating all care providers who insert PICC, we changed our practice to use plain radiography as first modality for PICC tip visualization starting June 1, 2019. CER was only used if catheter tip was not visualized on plain radiography. We collected the information on infants who had PICC inserted in the NICU before and after the implementation of the initiative for a given period.

Outcome measures were a) proportion of infants with PICC tip visualized on first plain radiography (b) proportion of infants who received CER (c) Number of X-rays per line insertion. We compared the data regarding the above outcomes between the two time periods.

Results

Of the 113 PICC inserted, 39 PICCs were inserted during routine CER period, and 74 PICCs were inserted during PR period. The mean gestational age (26 ± 2.8 vs 27± 3.5), birth weight (878 ± 406g vs 1024g ± 559g, site of insertion - upper limb PICC (74% vs 69%) were comparable between the two groups.

Catheter was visualized on first plain radiography in 56/74 (75%) in the PR period. Overall, the CER was performed in 30/74 (40%), of which 18 were for non-visualization of tip on first plain radio-graph and 11 for non-visualization after subsequent manipulation. There was no difference in the median (IQR) number of radio-graphs between CER period and PR period [2 (2-3) vs 2 (1-3), p =NS] with similar proportion of infants requiring 2 or less X-rays (71% vs 67%).

Conclusion

The use of plain radiography as the initial imaging modality is a safe alternative, without increasing radiation exposure and it minimizes the use of intravenous contrast in neonates undergoing PICC insertions. In spite of being superior for tip visualization, CER does not reduce the number of X-rays taken for the same purpose.
46 Preparation for MRI through imaginary visualization of an astronaut’s rocket journey to space for children 3 to 7 years old
Authors: Truchon Laurence , Lacombe Catherine , Doyon Myriam , Tremblay-Roy Jean-Sébastien , Cyr Claude , Choker Ghassan , Roulier Sébastien , Patenaude Yves , Santschi Miriam
Published: August 2020

Background

Medical imaging by magnetic resonance imaging (MRI) is now frequently used in the pediatric population. Up to now, sedation is used almost systematically to provide adequate immobilization during the exam. However, sedation is not without risks.

Objectives

The objective of this study is to evaluate whether a prior familiarization to MRI procedures with a video staging the imaginary world of an astronaut’s rocket journey into space will decrease the number of required sedations for an MRI for children aged 3 to 7 years old.

Design/Methods

A total of 136 children between 3 and 8 years of age, referred for an MRI between April 2016 and October 2019, were recruited for this prospective non-randomized quasi-experimental study. The control group (April 2016 to August 2017, n=73) received the usual sedation protocol for MRI used in our center. A pictorial step-by-step brochure and a three-minute video explaining the parallel between the MRI reality and the imaginary world of an astronaut was developed and shown to the intervention group (July 2018 to October 2019, n=63) before the MRI. Compared to the control group, any MRI in the intervention group was first attempted without sedation.

Results

A significant decrease in the number of sedations was observed in the intervention group (n=18; 28.6%) compared to the control group (n=47; 64.4%) (odds ratio: 0.22; p <0.001). The effect of the intervention was even stronger for younger children (3 and 4 years old) (odds ratio: 0.03) compared to older children (5 years old and above) (odds ratio: 0.3). After logistic regression, age remained the sole other significant factor to influence the need for sedation, even in the intervention group.

Conclusion

A video and a brochure staging the imaginary world of an astronaut’s rocket journey into space showed just before a MRI significantly reduces the rate of sedation in children aged 3 to 7 years, especially for young children. We believe the implementation of interventions using imaginary visualization in this age group should be widely used to limit the necessity of sedation.
53 Implementation of a Developmental Outreach Clinic housed within a Family Health Team - preliminary findings in building a shared care model for children and youth with mental health and developmental disorders
Authors: Young Elizabeth , Goldfarb Rachel , Green Laurie , Hollamby Kathleen , Weyman Karen , Jackson Linda , Milligan Karen
Published: August 2020

Background

At our inner city hospital, we developed a shared care model between family health teams (FHTs), pediatricians and developmental pediatricians to care for children with mental health and developmental disorders. In phase one of our study, 84 FHT members participated in focus groups to inform the development of our clinic. Family physicians described their role as “referral agent”, “long term supporter” and “healthcare coordinator”. They expressed the desire to “learn” and “do more”, but noted barriers to providing care, including limited training, lack of service knowledge, limited communication, and cumbersome access to mental health and dual diagnosis services. Phase One was completed and accepted for publication. Phase Two describes the implementation of our clinic using a mixed methods approach and report preliminary findings.

Objectives

To evaluate the first two years of implementation of the developmental clinic housed within a family health team (FHT) an obtain feedback from members of the shared care model.

Design/Methods

Mixed methods were used including chart review of all patients referred to the clinic and semi structured interviews with primary care physicians, pediatricians and developmental pediatricians regarding their roles in managing children with developmental and mental health disorders, as well as use and impact of the developmental clinic.

Results

A total of 115 charts were reviewed between Feb 2016 and Jan 2018. Of all patients seen, 34% were female 64% male and 2% transgender. Ages ranged from 1-17 years. Eighty-one percent had an existing diagnosis and were referred for re-assessment while 43% received a new diagnosis: ASD (72%), ADHD (11%), GDD (11%), learning disorder (3%), Anxiety (1%), Other (1%). There was an 8% no show rate. Providers endorsed improved communication through use of a shared EMR for documentation and messaging, and improved service knowledge through availability of a pediatric service navigator who also used EMR to document service and funding applications. Longer term follow up, namely the roles and responsibilities of pediatrics vs. developmental pediatrics vs. primary care remained unclear.

Conclusion

Implementation of the shared care model for this population with primary care is feasible, and does address some stated barriers to care, including improved communication, increased service knowledge, and provision of reassessments. Further areas to develop include clarifying the roles and responsibilities of the different healthcare providers of children with mental health and developmental disorders, and determining what is needed for long-term follow up and transitional care.
54 Consistency in a Pediatric Developmental Disability Elective for Preclinical Medical Students: Five Years of Student Experience
Authors: Simin Irina , Thornton Siobhan , Fong-Leboeuf Alexis , Andrews Debra
Published: August 2020

Background

There is an increasing recognition for medical students to receive more training in caring for patients with developmental disabilities (PWDD). Studies have found that providing training and encounter opportunities with PWDD for medical students improves their attitudes, comfort level, and knowledge. PWDD can have more sensitivity to changes in health than others, highlighting the importance of providing educational opportunities for medical professionals. To mitigate these outcomes, this preclinical 12-hour elective: “Developing Skills for Developmental Disabilities” (DSDD) was developed with the primary learning objective of improving students’ knowledge of and attitudes toward developmental disabilities in pediatrics.

Objectives

The current study’s objective was to evaluate the consistency of students’ perceived confidence ratings in assessing and managing children presenting with developmental delay or disability, despite changes in workplace educational setting across 5 years.

Design/Methods

Students received 6 hours of content-specific didactic teachings in addition to the standard second year developmental pediatrics curriculum. Content was provided by a team of developmental pediatricians and physiatrists. Didactic session topics included child development, estimating developmental age, assistive technologies, and breaking bad news, to supplement the 6 hours of clinical experience at a rehabilitation hospital. Students attended medical assessments with the opportunity to conduct a brief interview with the child’s family, observe pediatric PWDD in treatment programs, and interact with interdisciplinary teams. Students were given pre- and post-elective self-assessment surveys administered on a 5-point Likert scale. Questions pertained to students’ self-perceived comfort and knowledge regarding pediatric PWDD. Scores pre- and post-elective were used to calculate relative improvement of participants.

Results

120 students enrolled in DSDD, with 94 students meeting elective requirements. On average, 77.2% (SD = 6.2%) of students were female and 81.4% (SD = 12.9%) reported having prior experience with PWDD. Statistically significant (p<0.05) relative improvements were present in 9 of 10 scores for 2 of 5 years and all 10 in the other 3 years. Improved scores involved increases in confidence in interacting with PWDD, taking histories, recommending appropriate resources to families, and estimating developmental age.

Conclusion

DSDD may support acquisition of clinically relevant skills beyond those learned in the standard curriculum, as students consistently reported improvements in confidence across the same domains over 5 cohort years of this elective. The demonstration of maintained improvement is important because it may be translatable to future clinical practice and have implications towards optimizing outcomes for pediatric PWDD.