bluuebunny/crossref_metadata_2025 huggingface dataset:
BARRIERS TO IMPLEMENTATION OF EARLY PEANUT INTRODUCTION AMONG PEDIATRICIANS, FAMILY PHYSICIANS, AND ALLERGISTS
Authors: Singer Alexander , Abrams Elissa , Soller Lianne , Chan Edmond
Published: May 2018

BACKGROUND

The approach to peanut allergy prevention has shifted with publication of the Learning Early About Peanut (LEAP) trial and recently released NIAID guideline recommending early peanut introduction in high risk infants.

OBJECTIVES

Our objective was to determine whether current practice patterns at both the allergist and primary care level are in keeping with the LEAP recommendations and NIAID guideline.

DESIGN/METHODS

A 17-question survey was distributed in 2016 to Canadian allergists through the Canadian Society of Allergy and Clinical Immunology, paediatricians through the Canadian Paediatric Society, and a sample of practicing family physicians.

RESULTS

There was variability in the definition of infants at high risk for peanut allergy and recommendations for age of introduction of allergenic solids. There was also variability in how often allergist evaluation was recommended for infants with egg allergy or severe eczema prior to peanut introduction, with allergists 9 times more likely to recommend pre-emptive peanut testing in infants with severe eczema prior to peanut introduction. The majority of family physicians (77.1%), paediatricians (91.4%) and allergists (89.1%) did not believe there was harm to introduction of solids between 4–6 months of age, or that breastfeeding rates would be affected with earlier solid introduction.

CONCLUSION

Further education about the implications of LEAP is required. There are broad issues (such as the definition of a high risk infant) that require international consensus. Most primary care physicians and allergists do not believe there are harms to introduction of allergenic solids prior to 6 months of age, or that breastfeeding rates will be affected.
EMERGENCY DEPARTMENT VISITS BY CHILD REFUGEE CLAIMANTS AT A PEDIATRIC TERTIARY CARE CENTER
Authors: Evans Andrea , Ratnapalan Savithiri
Published: May 2018

BACKGROUND

The Canadian government has announced the resettlement of 50 000 refugees from the Middle East by 2018. The proportion of refugees that are below 18 years of age have increased from 20% to almost 40% from 2005 to 2014 and is expected to increase further with new refugee influxes. Barriers to timely health care can worsen clinical presentations and outcomes, especially in vulnerable children such as refugees. This study aims to provide an overview of the epidemiology, clinical presentations, hospital stay metrics, and non-clinical support needs for child refugee claimants presenting to the emergency department at a large tertiary care hospital in Canada.

OBJECTIVES

To describe the emergency department visits by refugee claimants with IFH, including demographics, primary care access, immunization status, acuity of presentation, repeat visits, and admission rates.

DESIGN/METHODS

A retrospective chart review of all refugee children presenting to the emergency department at this tertiary care hospital from April 1 2014 to March 31st 2017. A case was defined as a child who presented to the hospital with Interim Federal Health (IFH) which is the federal health insurance program covers newly arrived refugee claimants in Canada. Descriptive statistics and chi square test for categorical data was used. Data was analyzed using SPSS v21 IBM 2012. Ethics was approved by the Ethics Review Board of the hospital.

RESULTS

In total, there were 646 visits to the emergency department by 388 patients with IFH. The average age was 6.4 years (IQR 2.9–9.3), of which 58% were females. Travel history was documented in 65% of cases. The majority of patients arrived from Southeast Asia and the Middle East. The average time spent in Canada was 217 days (IQR 78–205). Sixty percent of patients did not have an identified primary care provider. Those with an identified primary care provider had more non-acute (CTAS 4–5) visits than those without an identified primary care provider (p<0.05). Immunizations were not up-to-date per Canadian standard in 25% of those who had an immunization history documented. Translation services was used in 11% of visits. Admission rate was 12%, with average length of stay 3.4 days (std 4). Top three reasons for admission were febrile neutropenia, respiratory distress, and blood per rectum. One fifth (20%) of admissions occurred on the same day as the arrival of the patient to Canada.

CONCLUSION

A significant number of refugee children are needing emergency care and admission to hospital on the day they arrive to Canada. Most child refugees presenting to the emergency department did not have an identified primary care provider, and a quarter did not have up-to-date immunizations. Association with primary care provider suggests that linkage to primary care in this population should be a priority.
EMERGENCY DEPARTMENT AND INPATIENT CLINICAL DECISION TOOLS FOR THE MANAGEMENT OF FEBRILE YOUNG INFANTS AMONG TERTIARY PEDIATRIC CENTERS ACROSS CANADA
Authors: Burstein Brett , Gravel Jocelyn , Aronson Paul , Neuman Mark
Published: May 2018

BACKGROUND

With no nationally endorsed guidelines and newer diagnostic tools, there exists widespread practice variation in the management of febrile infants <90 days.

OBJECTIVES

This study sought to evaluate the prevalence of clinical decision tools (CDTs) for the management of febrile young infants in the Emergency Department (ED) and inpatient settings among all tertiary paediatric centers across Canada.

DESIGN/METHODS

A cross-sectional, Internet-based survey was distributed to both an ED and an inpatient physician representative at each of the 16 Canadian tertiary paediatric centers. Participants were asked to characterize their clinical settings, diagnostic test availability and institutional febrile young infant CDTs. Copies were requested of all febrile infant-specific materials for independent classification as clinical pathway, guideline or order set, and content review using list items determined a priori. The primary analysis was the proportion of settings that use a CDT for the management of febrile infants. Chi-square testing was used to compare proportions.

RESULTS

Survey response rate was 100% (n = 32, 16 ED and 16 inpatient). Febrile young infant CDTs of any type were infrequently reported overall (9/32, 38%), and were more common in the ED than inpatient setting (50% vs. 6%, p=0.02). Prevalence of any CDT was not associated with hospital volume or physician training. Among EDs, clinical pathways, guidelines, and order sets were available at 6/16 (38%), 1/16 (6%), and 4/16 (25%) institutions, respectively. Among centers reporting existent CDTs, few reported ED or inpatient tracking of provider adherence or audits of impact (3/9, 33% overall). Review of existing CDTs revealed inter-center differences for inclusion ages, antibiotic treatment regimens, lumbar puncture recommendations, diagnostic testing and normal laboratory reference values. Despite wide availability reported at nearly all centers, C-reactive protein and respiratory viral testing were each rarely incorporated into existent CDTs (3/9, 33% for both). Procalcitonin testing was reported to be available at 2/16 (13%) centers, and was not incorporated into any existing CDTs.

CONCLUSION

CDTs for the management of febrile young infants are infrequently available among Canadian tertiary paediatric centers, and when present, rarely contain information on newer diagnostic tests. The paucity of CDTs among paediatric academic training centers may in part underlie ongoing practice variation. Heterogeneity among existent CDTs highlights the need for the establishment of updated and unified ED and inpatient national guidelines.
RELATIONSHIPS BETWEEN NEAR-INFRARED SPECTROSCOPY, PREDUCTAL PERFUSION INDEX AND CARDIAC OUTPUTS IN EXTREMELY PRETERM INFANTS IN THE FIRST 72 HOURS OF LIFE
Authors: Janaillac Marie , Beausoleil Thierry , Karam Oliver , Raboisson Marie-Josée , Barrington Keith J , Dehaes Mathieu , Lapointe Anie
Published: May 2018

BACKGROUND

Assessment of hemodynamics during the transitional period in preterm infants is challenging.

OBJECTIVES

We aimed to describe the relationship between cerebral regional tissue oxygenation saturation (CrSO2), preductal perfusion index (PI), echocardiographic and clinical parameters in extremely preterm infants in their first 72 hours of life.

DESIGN/METHODS

This single center prospective observational study was conducted in the level 3 neonatal intensive care unit of Sainte-Justine Hospital between July 2015 and May 2016. Twenty newborns born at <28 weeks of gestation were continuously monitored with CrSO2 and preductal PI as well as cardiac outputs measured at 6, 24, 48 and 72 hours of life. Data were assessed for normality and Pearson correlation statistics were performed. Serial data were tested using a one-way ANOVA with repeated measures and Bonferroni adjustment. The level of significance was set to 0.05

RESULTS

Median gestational age and birth weight were 25.0 weeks (24–26) and 750 g (655–920) respectively. Table 1 describes the measures over the 72 hours of the study period. CrSO2 and preductal PI were weakly correlated with mean blood pressure, PaCO2, lactates and haemoglobin. Fifteen patients had at least one episode of low left and/or right ventricular output (RVO) measured and showed strong correlation between CrSO2 and superior vena cava (SVC) flow at H6 (r=0.74) and H24 (r=0.86) and between PI and RVO at H6 (r=0.68) and H24 (r=0.92). Five patients had low SVC flowat H6 and showed strong correlation between PI and RVO (r=0.98).

CONCLUSION

CrSO2 and preductal PI were weakly correlated with clinical parameters in the preterm infants. However, CrSO2 and PI showed stronger correlation with RVO and SVC flow during low cardiac output states.
BOVINE LIPID EXTRACT SURFACTANT (BLES®) ADMINISTRATION USING A MINIMALLY INVASIVE APPROACH
Authors: da Silva Orlando , Bhattacharya Soume , Read Brooke , McGovern Evelyn
Published: May 2018

BACKGROUND

There is growing evidence that surfactant delivery via a thin endotracheal catheter during spontaneous breathing; a technique called minimally invasive surfactant therapy (MIST) is an alternative to intubation and surfactant administration. The majority of studies evaluating the MIST technique have utilized a higher concentration; lower volume surfactant at a dose of 2.5ml/kg. Little evidence is available describing the feasibility of administering a lower concentration, larger volume surfactant at a dose of 5ml/kg utilizing the MIST technique.

OBJECTIVES

To describe the feasibility of utilizing Bovine Lipid Extract Surfactant (BLES®) with the MIST technique within a single tertiary centre after a change in practice.

DESIGN/METHODS

A guideline for surfactant administration (BLES® – 5 ml/kg) using the MIST technique was developed in our centre in 2016. Infants with a birth weight ≥ 1000 g and ≥28 weeks gestation were deemed eligible candidates for this technique if they developed RDS and met criteria for surfactant administration (FiO2 requirement greater than 40% on nasal continuous positive airway pressure (NCPAP) and were clinically well apart from respiratory distress. Surfactant was administered via a thin catheter (KimVent® Multi-Access Catheter) which was inserted into the trachea using Magill forceps, while the baby continued to breathe spontaneously on NCPAP. Depth of catheter insertion was estimated using 6 cm + weight in kg. Surfactant was instilled into the trachea over 1–3 minutes and the delivery was timed to coincide with inspiration. Administration of sucrose was recommended and of atropine was optional prior to laryngoscopy for insertion of the endotracheal catheter.

RESULTS

Since implementation of the new guidelines, a total of 22 infants received surfactant by the MIST method. The mean gestational age was 32 ± 2.6 weeks and mean birth weight was 1972 ± 788g. Five infants (22.7%) had transient bradycardia and desaturations during the procedure. Five infants (22.7%) required intubation post MIST procedure at variable times (range 6–29 hours), 3 infants (14%) for increasing oxygen requirements and a second dose of surfactant and 2 (9%) infants for hypercapnia and poor respiratory drive. Twenty infants (90%) were successfully weaned to 21% oxygen on NCPAP post procedure at a median duration of 0.5 (range 0.01–29) hours.

CONCLUSION

The delivery of BLES® using the MIST technique for RDS was overall well tolerated by the patients and shown to be an effective alternative to more invasive methods.
ÉVALUATION À LONG TERME DES PATIENTS AVEC ANNEAUX VASCULAIRES COMPLETS AU CHU DE QUÉBEC
Authors: Desjardins Laurent , Vaujois Laurence , Houde Christine , Drolet Christian , Perron Jean , Jacques Frédéric
Published: May 2018

BACKGROUND

Les anneaux vasculaires complets (AV) sont des anomalies rares des gros vaisseaux. Ils sont souvent symptomatiques en bas âge et nécessitent une chirurgie dans la grande majorité des cas. Les deux formes les plus communes sont les double arc aortique (DAA) et arc aortique droit avec ligament artériel et artère sous-clavière gauches aberrante (AADSCGA). L’approche chirurgicale et la prise en charge à long terme demeurent débattues dans la littérature, en plus, certains patients demeurent symptomatiques après la chirurgie.

OBJECTIVES

Évaluation à long terme des patients opérés pour un AV.

DESIGN/METHODS

Étude rétrospective observationnelle des patients diagnostiqués avec un AV.

RESULTS

Soixante-six patients ont été diagnostiqués avec un AV (16 patients avec DAA et 50 avec AADSCGA +/- diverticule de Kommerell (DK)). Au diagnostic, 61% étaient symptomatiques (39% symptômes respiratoires, 27% symptômes digestifs hauts, 6% les deux), alors que 20% ont été diagnostiqués dans le cadre d’une anomalie cardiaque associée; chez les autres, il s’agissait d’une découverte fortuite. Trente-huit pourcent des patients avaient une anomalie cardiaque associée. Vingt-trois pourcent des patients avaient un syndrome génétique, dont 53% étaient des syndromes de DiGeorge. Douze patients ont eu un diagnostic concomitant de trachéomalacie. Les patients avec DAA ont été diagnostiqués plus tôt (1.8 ± 3.6 vs 5 ± 8.3 ans, p=0.038) et opérés plus précocement après le diagnostic (82 ± 123 vs 264 ± 416 jours, p=0.036) que les patients avec AADSCGA. Une chirurgie a été effectuée chez 67% des cas, avec 34 patients (77%) subissant une division avec aortopexie. Aucun patient n’est décédé des suites de sa chirurgie. Deux patients ont dû avoir une seconde chirurgie pour des symptômes secondaires à l’AV. Au dernier suivi, 16 patients demeuraient symptomatiques au niveau respiratoire (aucun symptôme digestif), dont 9 patients opérés (20%). Sept patients ont eu une investigation supplémentaire par spirométrie, par contre, aucun n’a eu d’imagerie additionnelle.

CONCLUSION

Les AV sont des anomalies rares et se présentent habituellement dans la première année de vie. Une chirurgie est généralement curatrice et sécuritaire. Néanmoins, plusieurs patients opérés demeurent symptomatiques au dernier suivi. Il serait probablement judicieux d’investiguer ces patients par imagerie pour préciser la cause de la symptomatologie résiduelle.
EXAMINING REFERRAL PATTERNS AND DIAGNOSTIC RATES IN THE BRITISH COLUMBIA AUTISM ASSESSMENT NETWORK
Authors: Ip Angie , Weikum Whitney , Lanphear Nancy
Published: May 2018

BACKGROUND

Most children in British Columbia are assessed for ASD by the BC Autism Assessment Network (BCAAN). While all diagnostic clinicians in BCAAN follow the same diagnostic standards, there is no published data on the referral patterns within BCAAN.

OBJECTIVES

We aimed to examine whether patients referred by different clinician types have different ASD diagnostic rates.

DESIGN/METHODS

This was a retrospective cross-sectional study using data from the BCAAN database consisting of individual patient data from January 1, 2010 to December 31, 2016. The analysis included all patients aged 0 to 18 years. Sequential logistic regression models were built to look at the effect of referring clinician type on ASD diagnostic outcome. The ASD diagnostic outcome was a binary outcome of whether a child was diagnosed with ASD. The main predictor variables were the referring clinician type. Other predictor variables examined as confounders included age and sex of the child, the referring health region, and the year the child was assessed. Changes in effect size, standard deviation, and Akaike information criterion were used to examine model fit.

RESULTS

Twenty patients did not have data for referring clinician type, 5 did not have diagnostic outcome data, and only 27 patients were referred by a nurse; they were not included in the analysis. The final dataset included 12,058 unique patients; they were not included in the analysis. The final dataset included 12,058 unique patients; 7271 (60%) were diagnosed with ASD. The ASD positive diagnostic rate for referrals by paediatricians (n=5704) was 61%, by family physicians (n=886) was 60%, by psychiatrists (n=483) was 51%, and by speech language pathologists (SLPs, n=198) was 68%. Using paediatricians as the reference group, the odds ratio of being diagnosed with ASD in the final model for children referred by a family physician was 1 (95% CI = 0.89–1.12); for children referred by a psychiatrist, the odds ratio was 0.87 (95% CI = 0.75–1); for children referred by an SLP, the odds ratio was 1.69 (95% CI = 1.28–2.25). These findings showed that within our study population, children referred by SLPs were more likely to be diagnosed with ASD and there was no statistically significant difference in ASD diagnostic rate for children referred by paediatricians, physicians, and psychiatrists.

CONCLUSION

Electronic clinical data is a valuable tool in examining referral and diagnostic patterns and generating data guided questions and hypotheses. Findings from this study suggest that the process of SLP referrals as well as differences between family physicians who refer to BCAAN versus the general population of family physicians should be explored as areas for reducing referral delays for children at risk of ASD.
THE YIELD OF A UNIFIED SCREEN FOR THE INVESTIGATION OF INBORN ERRORS OF METABOLISM IN CHILDREN WITH NEURODEVELOPMENTAL CONDITIONS – A RETROSPECTIVE CHART REVIEW
Authors: Nahhas Norah , Peltekova Iskra , Buhas Daniela
Published: May 2018

BACKGROUND

Neurodevelopmental conditions (NDCs) such as Global Developmental Delay (GDD), Intellectual Disability (ID) and Autism Spectrum Disorders (ASD), are clinically heterogenous. Many of their etiologies are genetic. Previous studies report differing detection rates of inborn errors of metabolism (IEM) as causes of NDCs. Small sample sizes, poorly defined populations and variable diagnostic approaches limit these studies. Improved detection and treatment of IEM demands a better understanding of the diagnostic yield of the investigation of IEM as an etiology of NDCs. This will help establish a streamlined process in the diagnostic evaluation NDCs.

OBJECTIVES

The objective of this project is to establish the detection rate of IEM in a well-characterized cohort of children with NDCs, investigated for IEM with a unified screening test panel. This study was approved by the Research Ethics Board.

DESIGN/METHODS

This is a retrospective medical chart review of children with NDCs (GDD, ID and/or ASD), aged 0 to 18 years, diagnosed at a Canadian quaternary center. Charts were collected between March 2015 and 2016. The children were seen for a diagnostic work-up in Developmental Paediatrics, Neurology or Genetics clinics. As part of the standard investigation these services use a unified test panel for screening for IEM. Data was collected on the yield of metabolic testing.

RESULTS

Out of 188 children with NDCs fulfilling the inclusion criteria, 115 (61.1%) underwent the complete IEM screening panel, 52 (27.6%) had partial work-up and 21 (11.2%) did not undergo tests for IEM. The average age of the children was 5 years. Children had the following: ASD (104, 55.3%), GDD (68, 36.2%), ID (10, 5.3%), ASD and ID (6, 3.2%). The diagnostic yield for IEM in those who underwent the entire IEM screening panel was 2.6% (3 confirmed IEM). Three additional children have results suspicious for IEM, but are awaiting confirmatory testing. This suggests that the yield may be as high as 5.2%. Two (3.8%) children with partial IEM work-up also have abnormal metabolic results but diagnoses of IEM are pending.

CONCLUSION

The detection rate of IEM in the children with NDCs, who underwent screening with a unified test panel, was 2.6%. However, given that confirmatory investigations for other children were pending at the time of our study, the actual yield is likely higher. Therefore, IEM should be considered as an etiology in the routine investigation of NDCs. Screening for IEM should be done in a systematic manner.
LIKELY BACTERIAL ACUTE CERVICAL LYMPHADENITIS IN CHILDREN: FACTORS PREDICTIVE OF FAVORABLE OUTCOME
Authors: Deshaies-Poliquin Karina , Arsenault-Blanchard Laurence , Marceau Alexandre , Belanger Richard , Berthelot Simon , Philippon Daniel , Gagnon Josee Anne
Published: May 2018

BACKGROUND

Cervical lymphadenitis is frequent in the paediatric population and usually the result of infectious agents. Management of likely bacterial acute cervical lymphadenitis (LBACL) mainly relies on expert advice and may vary widely from antibiotherapy to surgery as no official guidelines have been published over the last decade.

OBJECTIVES

To identify factors associated with favorable outcome in the management of LBACL in children in order to create a decision algorithm and its further evaluation.

DESIGN/METHODS

This retrospective observational study was based on the review of medical records of patient from 1 month to 18 years old who have consulted for LBACL between July 2010 and July 2015 at a tertiary care paediatric center. LBACL were identified using electronic record databases (hospitalization, emergency). Patients were included if they had acute (≤10 days) episode of unilateral cervical mass of which the final diagnosis was LBACL. Exclusion criteria were: mycobacterial adenitis, Kawasaki disease, Cat-scratch disease, bilateral cervical lymph node involvement, congenital malformation, immunodeficiency or underlying neoplasia. Favorable evolution was defined as outpatient treatment or hospital stay of 48 hours or less without surgical drainage. To identify factors at initial consultation predictive of a favorable outcome, we performed univariate logistic regression models with several potential independent covariates, including, among others, age (years), size of lymph node (mm), fever (38,5°C), an antibiotic use prior to consultation, fluctuation, absolute white blood cell count (x10^9/L), and purulent material at ultrasonography (yes/no).

RESULTS

Our final study cohort was composed of 166 patients with a mean age of 4,5 years (3,5SD) and 62% male. Ultrasound was obtained in 139(83,7%) patients and cervical tomodensitometry in 31(18,7%). Surgical drainage was performed in 35(21,1%). Overall, 68(41,0%) patients presented a favorable evolution from which 27(16,9%) were treated as outpatient (figure1). Factors associated with favorable outcome were (OR; 95%CI): age (1.17; 1.06–1.29; p=0.002), absolute white blood cell count (0.91; 0.87–0.96; p=0.001), no antibiotic use prior to consultation (0.26; 0.07–0.92; p=0.037) and absence of purulent material on ultrasound (0.07; 0.02–0.29; p<0.001). Size of lymph node (0.98; 0.96–1.00; p=0,057) or fluctuation (0.71; 0.21–2.39; p=0.57) did not achieved statistical significance.

CONCLUSION

Older patients without prior antibiotic use, those with lower absolute white blood cell count and no purulent material on ultrasound seem to better evolve than other children with likely bacterial acute cervical lymphadenitis. A decision algorithm to identify patients eligible for conservative management should include those predictive factors.
PEDIATRIC IDIOPATHIC INTERVERTEBRAL DISC CALCIFICATION: A SINGLE INSTITUTION CASE SERIES OF A RARE DISORDER
Authors: Dushnicky Molly , Laxer Ronald , Kulkarni Abhaya , Shroff Manohar , Okura Hidehiro
Published: May 2018

BACKGROUND

Paediatric idiopathic intervertebral disc calcification (PIIVDC) is a rare, poorly understood condition with just over 300 reported cases in the literature since the first report in 1924. The condition is characterized by calcification of an intervertebral disc which can progress to inflammation or extrusion and lead to neck or spinal pain in some patients.

OBJECTIVES

We report a series of patients seen at a single institution with PIIVDC and outline the disease course, management and outcome and review the literature.

DESIGN/METHODS

A retrospective chart review was performed at a single institution spanning the period between January 2001 and February 2016 for diagnoses of PIIVDC. Patient age, gender, symptoms, and medical history and physical and neurologic findings were reviewed. Laboratory and imaging findings, management, follow-up, and outcome were also studied.

A literature review was carried out by MEDLINE and Embase, using the search terms “pediatric disc calcification” and “disc calcification in children” between the years 1997 and 2017, in the English language. Articles were reviewed and data was extracted.

RESULTS

Nine cases of PIIVDC were identified (6 males, 3 females) with an age range of 1 to 14 years. Two patients were asymptomatic and PIIVDC was discovered incidentally. Of the remaining patients, five presented with neck/back pain, one painless torticollis, and one painful torticollis. One patient was noted to have pain radiating along one dermatome. Disc spaces affected were five cervical, five thoracic, and two lumbar, with two patients having more than one space affected. All patients were managed conservatively. In one case, symptoms and lesions persisted after 5-years, but the remainder had complete symptom resolution, generally within 6 months.

CONCLUSION

Although the etiology of PIIVDC remains unknown it appears to occur spontaneously, without preceding trauma or underlying medical condition. A conservative approach to patients without severe neurologic deficit with out-patient close follow-up is supported.
ANTIBIOTIC USE FOR INPATIENT BRONCHIOLITIS: DID NATIONAL GUIDELINES CHANGE PRACTICE?
Authors: Lopez Alison
Published: May 2018

BACKGROUND

Millions of infants and young children are affected by bronchiolitis annually around the globe. This viral lower respiratory tract infection often results in hospital admissions, thus impacting the cost of the healthcare system. Because of its heterogeneous clinical presentation, inpatient management practices amongst paediatricians varies widely. The publication of national guidelines by the Canadian Paediatric Society (CPS) in 2014 was aimed at decreasing the use of unnecessary investigations and therapies for inpatient management of bronchiolitis.

OBJECTIVES

To evaluate the levels of antibiotic prescriptions and supportive investigations for inpatient management of bronchiolitis before and after the publication of national guidelines.

DESIGN/METHODS

This study is a single-centre retrospective chart review of inpatients with confirmed cases of bronchiolitis. We included children with no other relevant co-morbidities, aged 1- 24 months, who were admitted from November 2011 – October 2016. We excluded those who were born less than 35 weeks gestational age and patients with chronic complex medical problems. Our inclusion and exclusion criteria mirrored those used in the CPS guidelines. Those admitted prior to December 2014 were analysed in the pre-guidelines cohort and the remaining were placed in the post-guidelines cohort. The main outcome was antibiotic prescription during the hospital stay. Secondary outcomes included the frequency of chest x-rays, nasopharyngeal swabs, and blood cultures.

RESULTS

131 patients were included in the first (pre-guideline) cohort and 71 in the second (post- guideline) cohort. The overall initiation of antibiotics was almost equal in both cohorts, regardless of whether a chest x-ray was ordered (p=1.000). There was no significant difference in the number of chest x-rays ordered between cohorts (p=0.099). The percentage of patients discharged on antibiotics were significantly lower in the second cohort (p=0.018). More antibiotics were discontinued after a viral cause was isolated in the second cohort (p=0.001). The gender distribution, mean age and mean length of stay were almost equivalent between the cohorts.

CONCLUSION

Our study did not show a significant change in antibiotic prescription despite the release of national guidelines. We found that isolating a viral aetiology often leads to the discontinuation of antibiotics. This study emphasizes the need for local antimicrobial stewardship initiatives to reduce the use of unnecessary antibiotics.
Do socio-economic determinants affect residential fire-related injuries and deaths among Canadian children?
Authors: Beaulieu Emile , Zheng Alex , Smith Jennifer , Pike Ian
Published: May 2018

BACKGROUND

Fire is a leading cause of unintentional injuries among children in Canada. More specifically, residential fires are responsible for too many preventable deaths and injuries. Yet, there is no national database that reports on residential fire-related injuries and deaths among children. Although socio-economic determinants (SED) have been associated with increased risk of residential fire in the USA and UK, little is known about the significance of this impact on the Canadian child population.

OBJECTIVES

This study examined the role of SED (low education, median income and average number of persons per dwelling (ANPD)) in residential fire-related injuries and deaths, and assessed the relationship between age and the severity of residential fire-related injuries and deaths, among children and youth in Canada.

DESIGN/METHODS

A cross-sectional study design was used to examine data from the National Fire Information Database (NFID), which includes 10-years (2005–2015) of microdata information on fire incidents and losses reported by provincial/territorial Fire Marshals and Fire Commissioners Offices across Canada. Census 2011 data at the CSD level, from Statistics Canada, provided the SED variables. Our outcome of interest was the odds of death and major injury over minor injury. A logistic regression model was applied to test the relationship between age and SED with our outcome of interest, while adjusting for province.

RESULTS

For every 1 person increase in the average ANPD at the CSD level, there is a 31% decrease in the odds of dying or being severely injured in a residential fire (p=0.0003). For every 1% increase in CSD’s low education proportion, there is a 2.5% increase in the odds of dying or being severely injured in a residential fire (p=0.0002). Median income was not significantly associated with the odds of death and major injury over minor injury. The odds of death and major injury were not significantly different for youths and adults, compared to children, controlling for ANDP, low education and median income.

CONCLUSION

The National Fire Information Database is one of the first to amass reliable fire incident and loss information across Canada into one database. Using this novel dataset, we determined that increased ANPD strongly decreased the odds of death and major injury over minor injury. Thus, the number of persons living in a household should be considered when targeting vulnerable children and youth for residential fire prevention and safety promotion programs.
THE DEVELOPMENTAL TOOLKIT: A PLAY-BASED LEARNING TOOL
Authors: Young Elizabeth , Jegathesan Thivia , Ng Stella , Mylopoulos Maria , Minhas Ripudaman S , Huber Joelene , Zubairi Mohammad
Published: May 2018

BACKGROUND

Learning child development is complex. Recent paediatric and family medicine graduates reported feeling unprepared to identify and manage children with developmental and behavioural concerns (Comley et al 2008). As part of current developmental education at our centre, residents are trained to assess child development by integrating their pre-rotation knowledge about development with parental report and a general physical examination. This approach lacks hands-on training required to understand and learn the complexities of child development. To address this gap, our study team created the “Developmental Toolkit (Toolkit),” a non-standardized developmental teaching tool comprising specific toys and activities.

OBJECTIVES

The primary objective of this study was to explore how the toolkit may influence the teaching and learning of child development. Through the lens of reflective practice, this study sought to also explore residents’ learning of development in the context of a play-based toolkit.

DESIGN/METHODS

Using a constructivist grounded theory approach, paediatric and family medicine residents from two academic centres were interviewed after they used the toolkit as part of their interactions. Physician supervisors were also interviewed to determine the use of the toolkit as a teaching tool.

RESULTS

We recruited 10 residents to ensure saturation of data. Residents felt positively about their experience with the toolkit and its ease of use. They all agreed the toolkit enabled them to assess a child’s developmental skills in a short period of time. One paediatric resident found it “really useful; it was a more objective way for me to see what skills and milestones they [the child] were at. I think it was quite useful to correlate it with what mom was saying.” The residents’ supervisors all felt the toolkit allowed residents to more critically consider a child’s development and diagnosis in the context of the child’s environment. Furthermore, through the lens of reflective practice,the use of the toolkit revealed additional competencies in child development. These included: 1) maintaining a positive mood with the child; 2) getting a sense of the parent’s mood; 3) identifying when a child may have reached their limits during an interaction; and 4) critiquing previous assumptions about child development.

CONCLUSION

The toolkit is an innovative tool that may enhance paediatric and family medicine residents’ understanding of child development by enabling hands-on interactions and observations with children. Further exploration of how the toolkit may be enabling reflective practice and its implications on adaptive expertise need to be explored.
PREPARING FOR CBME: HOW OFTEN ARE FACULTY OBSERVING RESIDENTS?
Authors: George Sheenagh , Manos Sarah , Wong Kenny
Published: May 2018

BACKGROUND

Transitioning to competency-based medical education (CBME) necessitates change in resident assessment. A greater frequency of resident observation will be required to adequately assess whether entrustable professional activities have been achieved.

OBJECTIVES

Characterize faculty and resident experiences of direct observation in a single Canadian Paediatric Residency program, pre-CBME implementation. Describe faculty and residents’ perceived barriers and incentives to participating in direct observation.

DESIGN/METHODS

Surveys were sent to faculty and residents asking for demographic information, the frequency of resident observation during an average 4-week rotation in several domains (taking a history, performing a physical examination, delivering a plan,...), perceived ideal frequency of observation, and factors influencing observation frequency. Descriptive data was analyzed. Institutional research ethics board approval was received.

RESULTS

The response rate was 54% (34/68 faculty and 16/25 residents). When asked the MAXIMUM frequency faculty observed a resident take a history, perform a physical examination, or deliver a plan, the median FACULTY reply was 1, 2, and 3, for outpatient settings and 0, 1, and 2, for inpatient settings, respectively. The median RESIDENT reply was 2, 4, and 10 for outpatient settings and 1, 2, and 20 for inpatient settings, respectively. When asked the MINIMUM frequency for each domain, the median FACULTY AND RESIDENT reply was 0, except for delivering a plan in the inpatient setting (median RESIDENT reply was 2). FACULTY and RESIDENT median replies for how frequently residents should ideally be observed for each domain were the same, 3–4, 3–4, and 5–6 times. 4% of faculty reported regularly scheduling observations, and 77% of residents regularly ask to be observed. The most common responses to barriers to observation were too many patients to see and that both faculty and residents were seeing patients at the same time. Most faculty and resident responders felt that observation frequency could be improved if they were scheduled at the start of the rotation, if faculty were provided a better tool for assessment, and if residents asked to be observed.

CONCLUSION

This study provides baseline data on how infrequent faculty observation of residents is occurring and at a frequency lower than what faculty and residents feel is necessary. The time needed for observation is felt to compete with clinical service demands, but better scheduling strategies and assessment tools may help increase the frequency of resident observation.
FEASIBILITY OF A MANUALIZED FAMILY-BASED SUICIDE PREVENTION STRATEGY TO REDUCE ADOLESCENT SUICIDE RISK AMONG EMERGENCY DEPARTMENT REFERRED YOUTH: A QUALITY IMPROVEMENT PROJECT
Authors: Tracey Matthew , Rowney Gillian , Pignatiello Antonio , Monga Suneeta , Korczak Daphne
Published: May 2018

BACKGROUND

Suicide is the second leading cause of death among Canadian children and adolescents. Youth who present at an Emergency Department (ED) for suicidal ideation and risk behaviours (SRB) are at increased risk for eventual suicide. Despite this risk, current approaches to standard of care are referral to community resources or primary care where waitlists are common, and interventions may not be evidence-based or incorporate crisis management or family participation.

OBJECTIVES

To determine the feasibility and acceptability of a manualized, family-centered suicide prevention intervention administered in an outpatient clinic for ED-referred youth.

DESIGN/METHODS

Youth (aged 12 – 18) and parents presenting to the ED for SRB and referred to the Urgent Psychiatry Care clinic were eligible for the QI program, consisting of weekly individual and family sessions delivered over a 6-week period. The therapist addressed common symptoms and concerns of suicidal youth, sources of conflict within the family, and ways to improve communication and ensure patient safety. Patients were excluded if they did not have a parent or caregiver able to participate.

Suicidal ideation and behavior were assessed using youth-report measures, the Suicidal Ideation Questionnaire-Junior (SIQ-JR) and the Harkavy-Asnis Suicide Scale (HASS), at baseline and following program completion. The Mood and Feeling Questionnaire (MFQ) was used to measure depressive symptoms. Participant and therapist feedback was collected at follow-up using quantitative and qualitative measures.

RESULTS

Ten patients were enrolled and completed baseline measures, however four participants withdrew prior to 6 week completion: two withdrew at week 2 and one participant each withdrew at weeks 3 and 6. As such, 7/10 completed 5 weeks of the intervention. Significant improvement in both suicidal ideation (SIQ-JR, x̅ = -16.67; t(5) = 3.125, p = .026) and SRB (HASS, x̅ = -20.17; t(5) = 3.204, p = .024) were observed. Depressive symptoms also decreased (MFQ, x̅ = -15.5, t(5) = 2.724, p = .042). Youth and caregivers rated the program favorably. Improved family communication was most frequently reported by both patients and caregivers as a main benefit of the program.

CONCLUSION

These preliminary data indicate that SRB may be improved by a brief manualized, family-focused therapy. Early data suggest that the protocol is feasible and acceptable for adolescents presenting to the ED with safety concerns, and warrant further examination in a controlled trial.
PAEDIATRIC SCHOOL OUTREACH: DEMOGRAPHICS AND CLINICAL NEEDS OF A UNIQUE INNER-CITY STUDENT POPULATION
Authors: Ng Pamela , Cohen-Silver Justine , Yang Heather , Swaminathan Aparna , Wormsbecker Anne
Published: May 2018

BACKGROUND

Paediatric School Outreach (PSO) clinic is a school-based health centre housed in a Kindergarten-Grade 8 public school. It serves an inner-city community impacted by the social determinants of health, such as language and income, which are barriers to accessing health care. This clinic focuses on developmental/behavioural, mental health and educational concerns.

OBJECTIVES

To characterize demographics, social determinants of health and some clinical characteristics of patients accessing services at PSO. By gaining a better understanding of the challenges of patients, services may be tailored to better suit patient/family needs.

DESIGN/METHODS

We conducted a retrospective chart review of children enrolled at PSO from November 2015 to March 2017. Data were obtained from demographic questionnaires and the electronic medical record. Analyses were performed in Microsoft Excel and SPSS (version 23) and are primarily descriptive. This work was funded by a faculty of medicine student research program and approved by research ethics boards at our hospital and school board.

RESULTS

138 children, between the ages of 2 and 15 years (average birth year 2008) enrolled at PSO during the study period. 73% were male. 70% of patients were in Grade 1 or above at enrolment. Children tended to be Canadian born to immigrant mothers; 74% of children were born in Canada but only 34% of mothers were also Canadian-born. After Canada, Hungary was the second common maternal place of birth (12%). English was the most common language spoken by patients (71%), followed by Hungarian, Tibetan, Portuguese and Spanish. 58% of patients’ families had a household annual income (HAI) of <$30,000 and 18% a HAI of $30,000–49,999.

84% of 138 patients reported having a family physician. Referrals were made by school support team (54%), teacher (36%) or principal (28%). The common presenting concerns were behaviour (81%), school performance (60%), followed by social communication (51%) and emotional presentation (49%).

Among 132 patients with clinical records, 13% were on any medication at enrolment; and 3% (4/132) on psychostimulants. 14% of patients were started on medication during the study period, most frequently psychostimulants (11%, 15/132).

CONCLUSION

PSO patients are culturally diverse and at least three quarters have HAIs below our city’s median of $65,829 (2015). The majority reported having a family physician but accessed our clinic for educational/behavioural concerns, suggesting PSO may be a stream-lined approach. With knowledge of maternal languages, we can begin to translate questionnaires and clinic materials. Further data analyses will better describe diagnoses and referrals made at the clinic.
Early Comparative Outcomes of Carbon Fiber–Reinforced Polymer Plate in the Fixation of Distal Femur Fractures
Authors: Mitchell Phillip M. , Lee Adam K. , Collinge Cory A. , Ziran Bruce H. , Hartley Kate G. , Jahangir A. Alex
Published: May 2018

Objective:

To evaluate the early clinical results of distal femur fractures treated with carbon fiber–reinforced polyetheretherketone (CFR-PEEK) plates compared with stainless steel (SS) lateral locking plates.

Design:

Retrospective comparative cohort study.

Setting:

ACS Level I trauma center.

Patients/Participants:

Twenty-two patients (11 SS, 11 CFR-PEEK) with closed distal femur fractures treated by a single surgeon over a 6-year period.

Main Outcome Measurements:

Nonunion, hardware failure, reoperation, time to full weight-bearing, and time union were assessed.

Results:

The CFR-PEEK cohort was on average older (71 vs. 57 years, P = 0.03) and more likely to have diabetes (P = 0.02). Nonunion was diagnosed in 4/11 (36%) patients in the SS group and 1/11 (9%) patients in the CFR-PEEK group (P = 0.12). Hardware failure occurred in 2 SS patients (18%) compared with none in the CFR-PEEK group (P = 0.14). Time to full weight–bearing was similar between groups, occurring at 9.9 and 12.4 weeks in the CFR-PEEK and SS groups, respectively (P = 0.23). Time to radiographic union averaged 12.4 weeks in the SS group and 18.7 weeks in the CFR-PEEK group (P = 0.26). There were 4 reoperations in the SS group and 1 in the CFR-PEEK group (P = 0.12).

Conclusions:

CFR-PEEK plates show encouraging short-term results in the treatment of distal femur fractures with a comparable nonunion, reoperation, and hardware failure rates to those treated with SS plates. This data suggest that CFR-PEEK plates may be a viable alternative to SS plates in fixation of these fractures.

Level of Evidence:

Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.
Case Report: Use of Sports and Performance Vision Training to Benefit a Low Vision Patient's Function
Authors: Laby Daniel M.
Published: May 2018

SIGNIFICANCE

Despite our inability to attenuate the course of many ocular diseases that can ultimately lead to loss or significantly decreased visual function, this report describes a potential technique to aid such patients in maximizing the use of the vision that remains.

PURPOSE

The aim of this study was to demonstrate the applicability of utilizing sports vision training to improve objective and subjective visuomotor function in a low vision patient.

CASE REPORT

A 37-year-old woman with Usher syndrome presented with reduced central visual acuity and visual field. Although we were unable to reverse the damage resulting from her diagnosis, we were able to improve the use of the remaining vision. A 27 to 31% improvement in hand-eye coordination was achieved along with a 41% improvement in object tracking and visual concentration. Most importantly, following the 14-week training period, there was also a subjective improvement in the patient's appreciation of her visual ability.

CONCLUSIONS

The sports vision literature cites many examples in which sports vision training is useful in improving visuomotor and on-field performance. We hypothesized that these techniques may be used to aid not only athletes but also patients with low vision. Despite suffering from reduced acuity and a limited visual field, these patients often still have a significant amount of vision ability that can be used to guide motor actions. Using techniques to increase the efficient use of this remaining vision may reduce the impact of the reduced visual function and aid in activities of daily living.
Mobility Analysis of AmpuTees II
Authors: Wurdeman Shane R. , Stevens Phillip M. , Campbell James H.
Published: May 2018

Objective

The aim of the study was to determine the impact of comorbidities on mobility in patients with lower limb prostheses.

Design

Cohort database chart review was conducted to examine mobility in lower limb prosthesis users grouped according to comorbidities. Regression models were used to determine significant predictor comorbidities for mobility. General linear univariate models were implemented to investigate differences in mobility among cohorts (N = 596).

Results

Patient age and history of stroke, peripheral vascular disease, and anxiety/panic disorders were predictors of decreased mobility. After adjusting for covariates, the differences in mobility reported by patients older than 65 yrs was compared with those younger than 65 yrs; in addition, we compared those with a history of peripheral vascular disease with those without. The comparative analyses for both categories did not satisfy the minimal clinically important difference. There were no significant differences when comparing overall comorbid health after adjusting for covariates.

Conclusions

Clinicians should consider patient age and history of stroke, peripheral vascular disease, or anxiety/panic disorders when optimizing a lower limb prosthesis users' mobility because these variables may be predictive of modest but clinically meaningful decreased prosthetic mobility. By contrast, common comorbid health conditions such as arthritis, chronic obstructive pulmonary disease, congestive heart failure, and diabetes do not seem predictive of decreased mobility among lower limb prosthesis users.