bluuebunny/crossref_metadata_2025_split huggingface dataset:
DEFINING PEDIATRIC DIABETES USING EMR RECORDS AND VALIDATION FROM LINKABLE MANITOBA COHORT DATA
Authors: Singer Alexander , Kosowan Leanne , Queenan John , Yeung Roseanne , Amed Shazhan , Wicklow Brandy 
Published: May 2018

Abstract

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

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

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

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

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

Abstract

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

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

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

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

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

Abstract

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

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

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

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

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

Abstract

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

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

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

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

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

Abstract

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

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

DESIGN/METHODS
Pre-intervention UE rate was determined by retrospective chart review for all intubated neonates admitted to a 25 bed level II/III NICU from January 2013 until December 2013. UEs were recorded along with demographic information including reason for extubation.
UE rate was calculated by number of UEs/100 ventilator days and the data was analyzed to determine any significantly associated risk factors. The UE quality improvement initiative included: multi-disciplinary NICU staff education sessions, placement of educational posters in the NICU and identification of high risk neonates as defined by the pre-intervention study. High risk neonates were given additional signage to alert care providers. Standardized documentation was implemented to track and record UEs prospectively. Six months post-implementation, all UE events were reviewed from December 2015 until May 2016 and the post-intervention UE rate was calculated.

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

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

Abstract

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

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

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

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

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

Abstract

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

OBJECTIVES
The primary objective is to compare the proportion of optimum UVC position (verified by ultrasound) using SM / BW based insertion depths formulas.
Secondary objective is to compare the proportion of optimum UVC position between the two methods based on birth weight, and growth status of the infants.

DESIGN/METHODS
In this prospective randomized trial, infants undergoing UVC insertion were randomly assigned to either SM or BW based formula. Infants with hydrops, major congenital heart disease, abdominal wall defects, or congenital diaphragmatic hernia were excluded. The optimum UVC position was then verified using ultrasound in addition to the standard radiography.
The primary outcome was optimum UVC position determined by ultrasound, read by an investigator blinded to the assignment. Optimum UVC tip position was defined as the catheter tip in the inferior vena cava between the hepatic vein confluence and right atrial opening. Intention to treat analysis was performed.

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

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

Abstract

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

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

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

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

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

Abstract

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

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

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

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

CONCLUSION
Cardiovascular dysfunction in neonates with disseminated HSV infection may be due to either primary ventricular dysfunction, vasodilatation and third space losses or due to pulmonary hypertension. Early targeted neonatal echocardiography may enhance physiologic definition and facilitate targeted therapy. Mortality from multisystem complications, however, remains universal, which raises the question of the role of ECMO in this population.