ALS Health care provider wellness

BACKGROUND

Interest in health care provider (HCP) wellness and burnout is increasing; however, minimal literature explores HCP wellness in the context of Amyotrophic Lateral Sclerosis (ALS) care.

OBJECTIVES

We sought to determine rates of burnout and resiliency, as well as challenges and rewards in the provision of ALS care.

METHODS

A survey link was sent to physicians at all Canadian ALS centers for distribution to ALS HCPs in their network. The survey included demographics questions, and validated measures for resiliency and burnout; the Brief Resilient Coping Scale (BRCS) and the Single Item Burnout Score (SIBS). Participants were asked to describe challenges and rewards of ALS care, impact of COVID-19 pandemic, and how their workplace could better support them.

RESULTS

There were 85 respondents across multiple disciplines. The rate of burnout was 47%. Burnout for female respondents was significantly higher (p = 0.007), but not for age, role, or years in ALS clinic. Most participants were medium resilient copers n = 48 (56.5%), but resiliency was not related to burnout. Challenges included feeling helpless while patients relentlessly progressed to death, and emotionally charged interactions. Participants found fulfillment in providing care, and through relationships with patients and colleagues. There was a strongly expressed desire for increased resources, team building/debriefing, and formal training in emotional exhaustion and burnout.

CONCLUSIONS

The high rate of burnout and challenges of ALS care highlight the need for additional resources, team-building, and formal education around wellness.

Increased breath naphthalene in children with asthma and wheeze of the All Age Asthma Cohort (ALLIANCE)

Exhaled breath contains numerous volatile organic compounds (VOCs) known to be related to lung disease like asthma. Its collection is non-invasive, simple to perform and therefore an attractive method for the use even in young children. We analysed breath in children of the multicenter All Age Asthma Cohort (ALLIANCE) to evaluate if 'breathomics' have the potential to phenotype patients with asthma and wheeze, and to identify extrinsic risk factors for underlying disease mechanisms. A breath sample was collected from 142 children (asthma: 51, pre-school wheezers: 55, healthy controls: 36) and analysed using gas chromatography-mass spectrometry (GC/MS). Children were diagnosed according to Global Initiative for Asthma guidelines and comprehensively examined each year over up to seven years. Forty children repeated the breath collection after 24 or 48 months. Most breath VOCs differing between groups reflect the exposome of the children. We observed lower levels of lifestyle-related VOCs and higher levels of the environmental pollutants, especially naphthalene, in children with asthma or wheeze. Naphthalene was also higher in symptomatic patients and in wheezers with recent inhaled corticosteroid use. No relationships with lung function or TH2 inflammation were detected. Increased levels of naphthalene in asthmatics and wheezers and the relationship to disease severity could indicate a role of environmental or indoor air pollution for the development or progress of asthma. Breath VOCs might help to elucidate the role of the exposome for the development of asthma. The study was registered at ClinicalTrials.gov (NCT02496468).

Canadian Pediatric Intensive Care Adaptations for Critically Ill Adults During the COVID-19 Pandemic: Survey Study

BACKGROUND

The COVID-19 pandemic overwhelmed Canadian hospitals with adult admissions. A large number of adult patients required critical care therapies, placing significant strain on hospital resources. In order to decompress adult intensive care units, pediatric intensive care units (PICUs) introduced adapted models of traditional care to lessen these burdens.

OBJECTIVE

We aimed to evaluate how PICUs across Canada adapted care for the high volumes of critically ill adults.

METHODS

A survey containing 40 questions was sent to the medical directors of 14 Canadian PICUs where English was the primary clinical language. The survey was designed to gain perspective on the various adaptations that PICUs instituted during the COVID-19 pandemic.

RESULTS

Of the 13 PICUs that returned survey responses (response rate: 13/14, 93%), 10 (77%) participated in at least one adaptation to support the influx of admitted adults with COVID-19. The key challenges included disorganization, loss of autonomy, and compromised patient care. The significant advantages of these adaptations included a sense of learning and comradery.

CONCLUSIONS

Our study highlighted an unpreparedness in critical care surge capacity. During the COVID-19 pandemic, adaptations rapidly emerged in Canada that involved PICUs with adult care. In the future, preplanned adaptations for optimizing robust critical care services should be developed based on what has been learned from the COVID-19 pandemic.

An examination of mercury levels in the coastal environment and fish of Cote d'Ivoire

Artisanal and small-scale gold mining (ASGM), energy production and other industrial inputs are a major source of anthropogenic mercury (Hg) to the aquatic environment globally, and these inputs have led to environmental contamination and human exposure. While studies have documented the effects of Hg inputs to rivers and marine waters of the West African region, estuarine waters of Cote d'Ivoire have been understudied, besides the waters surrounding Abidjan. To fill this gap, and to examine the potential for human exposure to methylmercury (MeHg), we measured the concentrations of total Hg, MeHg, and ancillary parameters in water (dissolved and particulate phases), sediment and fish to determine the extent of environmental impact and the potential for MeHg exposure for people consuming these fish. Levels of Hg and MeHg in sediment were elevated in the vicinity of the urban environment (up to 0.3 ng/g dry weight (dw) MeHg and 623 ng/g dw total Hg) and lowest in the more remote estuarine environments. Measurements of Hg in tuna and other larger pelagic coastal species indicated that levels were elevated but comparable to other North Atlantic regions. However, levels of Hg in fish, even smaller estuarine species, were such that the rural and urban populations are potentially being exposed to unsafe levels of MeHg, primarily as a result of the relatively high fish consumption in Cote d'Ivoire compared to other countries. Overall, both local point sources and the transport of Hg used in interior ASGM activities are the sources for Hg contamination to these coastal waters.

Severity of Illness Scoring for Pediatric Interfacility Transport: A North American Survey

OBJECTIVE

Severity of illness scoring during pediatric critical care transport may provide objective data to determine illness trajectory and disposition and contribute to quality assurance data for pediatric transport programs. The objective of this study was to ascertain the breadth of severity of illness scoring tool application among North American pediatric critical care transport teams.

METHODS

A cross-sectional quantitative survey using REDCap was distributed to 137 North American pediatric transport programs. Baseline team characteristics were established along with questions related to severity of illness tool application.Descriptive statistics were used for analysis.

RESULTS

There were 55 responses (40%), and of those, 13 (24%) use a severity of illness scoring tool within their practice. A variety of tools were used including: Transport Risk Index of Physiologic Stability, Children's Hospital Medical Center Cincinnati, Canadian Triage and Acuity Score, Transport Risk Assessment in Pediatrics, Pediatric Early Warning Scores, Levels of Acuity, Transport Pediatric Early Warning Scores, and an unspecified tool. The timing of scoring, team personnel who applied the score, and the frequency of analysis varied between transport programs.

CONCLUSIONS

Severity of illness scoring is not consistently performed by pediatric interfacility transport programs in North America. Among the programs that use a scoring tool, there is variability in its application. There is no universally accepted or performed severity of illness scoring tool for pediatric interfacility transport.Future research to validate and standardize a pediatric transport severity of illness scoring tool for North America is necessary.

Adult Admissions to a Canadian PICU during the COVID-19 Pandemic

In response to the burden of coronavirus disease 2019 (COVID-19) and overwhelmed intensive care unit (ICU) resources, some pediatric intensive care units (PICUs) have had to adapt. The purpose of this study was to assess the criticality, scope of diagnosis, and outcomes of an adult cohort admitted to a Canadian PICU. A retrospective chart review was completed on all patients between 17 and 50 years of age admitted to the PICU between June 2020 and December 2021. Admission data included body mass index (BMI), admission sequential organ failure assessment score (SOFA), COVID-19 status, diagnosis, and comorbidities. The duration of ventilatory support, PICU and hospital admission, and mortality and discharge disposition were assessed. Discrete variables were reported as percentages and continuous data as means with standard deviations or medians with interquartile range. Sixty-five adult patients were admitted to the PICU for a total of 437 days, with a mean SOFA score of 6.6 and the overall mortality rate of 4.6%. Six patients were diagnosed with COVID-19 pneumonia, were admitted with a mean SOFA score of 11.8 and a BMI of 38.3 kg/m2, and all were discharged to the ward. During the COVID-19 pandemic, pediatric intensivists in a Canadian PICU managed adult patients up to 50 years of age with high criticality and broad-ranging diagnoses with a low mortality rate. PICUs may be a safe critical care decompression option for adult ICUs during future endemics or pandemics.

Comparing subspecialty and intensive care providers perspectives on pediatric complex chronic patients: A survey study

Introduction

Pediatric complex chronic care patients present unique challenges regarding healthcare provision: complex medical regimes, complicated family/provider dynamics, and multiple healthcare teams that can result in inconsistent care. This study examined subspecialty providers’ perspectives regarding pediatric complex chronic care patients and compared them with acute care providers while exploring opportunities to better facilitate care provided to pediatric complex chronic care patients.

Methods

This survey study occurring within a Canadian tertiary care pediatric center, utilized REDCap to deploy surveys involving Likert Scale and short answer questions. The Kruskal–Wallis test compared subspecialty provider perspectives when providing care to pediatric complex chronic care patients versus non-pediatric complex chronic care patients; and perspectives between subspecialty and acute care providers.

Results

Survey response rate was 24/46 (52.2%). Eight overarching themes emerged from Likert scale questions. Short answer questions revealed factors that may facilitate care provided to pediatric complex chronic care patients: access to funding; discharge planning; communication methods between specialists; and healthcare provider continuity. Several differences were identified when working with pediatric complex chronic care patients, compared to non-pediatric complex chronic care patients: increased time/resource burden; managing expectations of patients/families; navigating discrepancies in goals of care; complexity of coordination between services; increased efforts in coordinating discharge from hospital and working with medicalized patients/families.

Discussion

Exploring pediatric subspecialty provider perspectives of pediatric complex chronic care patients revealed opportunities to enhance care provided: increased resources to ease the strain of care provision for parents, implementation of a discharge coordinator, complex care clinics with a pediatrician to “quarterback” care, and co-management between the complex care pediatrician and acute care physician when admitted to an acute care service. Implementation of these initiatives may improve the care provided to pediatric complex chronic care patients.

Evaluation of transport-related outcomes for neonatal transport teams with and without physicians

Objective

The aim of this study was to evaluate if the presence of a physician in the neonatal transport team (NTT) affects transport-related outcomes and procedural success.

Design

Retrospective cohort study with propensity score matching.

Setting

Canadian national study.

Patients

Neonatal transports from nontertiary centres between January 2014 and December 2017.

Interventions

Comparison of transports conducted by NTTs with physicians (MD Group) and without physicians (noMD Group).

Main outcome measures

The primary outcome was the change in patient acuity as measured by the transport risk index of physiologic severity (TRIPS) score. Secondary outcomes included mortality within 24 hours of NICU admission, clinical complications during transport, procedural success, and stabilization time.

Results

Among 9,703 eligible cases, 899 neonatal transports attended by NTTs with physicians were compared to 899 neonatal transports without physicians using propensity score matching. No differences were seen in the improvement of TRIPS score or mortality ≤24 hours of NICU admission. The MD Group had more clinical complications (7.7% versus 5.0%, P=0.02). No differences were seen in success rates of invasive procedures. The MD Group had shorter stabilization times. In multivariable analysis, the MD Group was not a significant predictor for the improvement in TRIPS score after adjustment for covariates.

Conclusions

Neonatal transports conducted by teams including physicians compared to teams without physicians, did not have higher improvement in TRIPS scores and had similar success rates for procedures. These results provide insights for the planning of the structure and training of specialized interfacility neonatal transport programs.

Serial Clinical Scoring to Assess Transported Pediatric Patients

OBJECTIVES

The objective of this study was to evaluate serial Transport Risk Assessment in Pediatrics (TRAP) scoring during pediatric critical care transport as a potential measure for specialized pediatric transport teams (PTTs).

METHODS

This was a retrospective study with a provincial PTT from a tertiary hospital pediatric intensive care unit. All acutely ill children who were transported by the PTT between 2018 and 2019 were included in the study. The TRAP scores were measured at time of transport team arrival (TRAP1), time at arrival to tertiary center (TRAP2), and 4 hours postarrival to tertiary center (TRAP3).

RESULTS

A total of 300 transports were included. Patients' mean age was 54 months, with lower respiratory tract infection (40.7%) as the most common diagnosis. There were significant differences between TRAP1-TRAP2 (P < 0.01) and TRAP1-TRAP3 (P < 0.01), but not between TRAP2-TRAP3 (P = 0.67). The most significant improvements of ΔTRAP1-TRAP2 scores were seen in septic shock (mean, 2.0; SD, 1.7).

CONCLUSIONS

The TRAP scores improved following the PTTs' arrival to acutely ill children, particularly with sepsis. Serial TRAP scoring may present a system for evaluation of team performance and/or characterize disease states that are positively impacted by PTTs. Future prospective evaluation is needed to validate TRAP for this purpose.

An Inconsistent Canadian Provincial and Territorial Response During the Early COVID-19 Pandemic

Objectives: According to the World Health Organization (WHO), an early and consistent international and national response is needed to control a pandemic's spread. In this analysis, we evaluate the coordination of Canada's early response to the coronavirus (COVID-19) pandemic in terms of public health interventions and policies implemented in each province and territory.

Methods: Retrospective data was obtained from publicly accessible websites maintained by federal, provincial and territorial governmental agencies. Consistent with WHO's spreading of the disease pandemic action, individual and community-based public health interventions and policies were the focus. Time of intervention or policy, and COVID-19 cases per million at time of intervention was recorded for each province and territory.

Results: Most public health interventions and policies demonstrated wide time ranges of implementation across individual provinces and territories. At time of implementation, there were also wide variations in the number of positive COVID-19 cases in these jurisdictions. Cases per million per implemented day were also not similar across interventions or policy, suggesting that other factors may have been preferentially considered.

Conclusions: Whether an earlier and more structured national approach would have lessened the pandemic's burden is uncertain, calls for greater federal coordination and leadership should to examined.

Perspectives of Pediatric Providers on Patients With Complex Chronic Conditions: A Mixed-Methods Sequential Explanatory Study

BACKGROUND

Children with complex chronic conditions present unique challenges to the pediatric intensive care unit, including prolonged length of stay, complex medical regimens, and complicated family dynamics.

OBJECTIVES

To examine perspectives of pediatric intensive care unit health care providers regarding pediatric patients with complex chronic conditions, and to explore potential opportunities to improve these patients' care.

METHODS

A prospective mixed-methods sequential explanatory study was conducted in a tertiary medical-surgical pediatric intensive care unit using surveys performed with REDCap (Research Electronic Data Capture) followed by semistructured interviews.

RESULTS

The survey response rate was 70.6% (77 of 109). Perspectives of health care providers did not vary with duration of work experience. Ten semistructured interviews were conducted. Eight overarching themes emerged from the interviews: (1) the desire for increased formal education specific to pediatric complex chronic care patients; (2) designation of a primary intensivist; (3) modifying delivery of care to include a discrete location for care provision; (4) establishing daily, short-term, and long-term goals; (5) monitoring and documenting care milestones; (6) strengthening patient and family communications with the health care team; (7) optimizing discharge coordination and planning; and (8) integrating families into care responsibilities.

CONCLUSIONS

Pediatric intensive care unit health care providers' perspectives of pediatric patients with complex chronic conditions indicated opportunities to refine the care provided by establishing daily goals, coordinating discharge planning, and creating occasions for close communication between patients, families, and providers.

Computed Tomography Practice Standards for Severe Pediatric Traumatic Brain Injury in the Emergency Department: a National Survey

Acute medical management of traumatic brain injury (TBI) can be challenging outside of the resuscitation bay, specifically while obtaining a computed tomography (CT) scan of the brain. We sought out to determine the management practices of Canadian traumatologists for pediatric patients with severe TBI requiring CT in the emergency department (ED). In 2019, surveys were sent to trauma directors in hospitals across Canada to ascertain their clinical practices. Team members present in the CT scan included physicians (89%), registered nurses (100%), and respiratory therapists (38%). The average time to and from the CT scanner was one hour. Over half of respondents (56%) had experienced an adverse event in CT with variable access (11-56%) to necessary resuscitation equipment and medications. Significant hypotension (44%) was the most common adverse event experienced. With the exception of an end tidal CO2 monitoring (56%), heart rate, rhythm, respiratory rate, saturation, and blood pressure were always monitored during a CT scan. Head of bed elevation had an approximately equal distribution of flat (44%) versus elevated (56%). The practice variability of Canadian traumatologists may reflect a lack of evidence to guide patient management. Future research and knowledge translation efforts are needed to optimize patient care during neuroimaging.

POS0006 NX-5948, A SELECTIVE DEGRADER OF BTK, SIGNIFICANTLY REDUCES INFLAMMATION IN A MODEL OF AUTOIMMUNE DISEASE

Background:

Aberrant activation of B cells and autoantibody mediated tissue damage are hallmarks of autoimmune diseases such as systemic lupus erythematosus (SLE) and rheumatoid arthritis (RA). Therefore, novel treatments that prevent autoantibody generation or antibody-mediated end organ tissue damage are of high interest. Bruton’s tyrosine kinase (BTK) transduces signals downstream of the B cell receptor (BCR), toll-like receptors, and Fc receptors in B cells and myeloid cells [1]. Overexpression of BTK in B cells leads to hyperactive BCR signaling, plasma cell generation, autoantibody secretion, and an SLE-like disease in mice [2]. Conversely, reducing BTK expression in B cells can ameliorate disease in Lyn-deficient mice.[3] BTK inhibitors, such as evobrutinib, have entered clinical studies for the treatment of autoimmune diseases.[4]

Objectives:

Small molecule-induced protein degradation offers a unique approach to target BTK; this approach simultaneously eliminates both BTK kinase activity and BTK-mediated scaffolding interactions in the signalosome. Chimeric Targeting Molecules (CTMs) are small molecules that catalyze ubiquitylation and proteasomal degradation of target proteins and are comprised of a ubiquitin ligase binding element (“harness”), a linker, and a target binding element (“hook”). NX-5948 is a CTM that contains a BTK hook linked to a cereblon (CRBN) harness. We examined the activity of NX-5948 in a collagen-induced arthritis model as part of an assessment of its potential as a drug candidate for autoimmune disease.

Methods:

Cellular degradation of BTK, Aiolos and Ikaros as well as induction of CD69 and CD86 was determined using flow cytometry. Degradation of BTK in CD-1 mice or cynomolgus monkey was determined using flow cytometry analysis. In a collagen-induced arthritis (CIA) model, mice were vaccinated with type II collagen and treated before the onset of symptoms. Serum cytokine and anti-type II collagen antibody levels were determined using Luminex and ELISA, respectively.

Results:

In human PBMCs, NX-5948 degrades BTK at sub-nanomolar concentrations and inhibits BCR signaling as measured by CD69 and CD86 induction in anti-IgM-stimulated B cells with similar potency. Oral administration of NX-5948 in mice leads to BTK degradation to <10% of baseline levels in circulating and splenic B cells. NX-5948 also promotes potent BTK degradation in cynomolgus monkeys, and it can suppress BTK levels to <10% of baseline levels after a single oral dose as low as 10 mg/kg.

Unlike IMiD drugs such as lenalidomide, the CRBN harness of NX-5948 was designed to avoid the degradation of known CRBN neo-substrates Aiolos (IKZF3) and Ikaros (IKZF1). In primary human T cells, NX-5948 induces minimal degradation of Aiolos and Ikaros and does not promote IL-2 secretion suggesting that NX-5948 does not convey IMiD activity associated with agents such as lenalidomide.

We examined the activity of NX-5948 in a mouse CIA model compared to that of the BTK inhibitor ibrutinib or dexamethasone as a positive control. In mice treated with NX-5948, symptoms of arthritis were resolved, and a significant reduction in arthritis clinical score was observed. Treatment with NX-5948 resulted in a reduction in anti-type II collagen titer and serum levels of the pro-inflammatory cytokine IL-6. Treatment with NX-5948 yielded superior anti-inflammatory activity relative to ibrutinib and similar activity to dexamethasone. Treatment with NX-5948 was well-tolerated and, unlike dexamethasone, did not promote body weight loss.

Conclusion:

Degradation of BTK by NX-5948 shows robust activity in a CIA model compared to existing agents tested as controls. These findings provide support for further investigation of NX-5948 in additional models of autoimmune disease to inform plans for clinical development.

References:

[1]Crofford et al. 2016. Expert Rev Clin Immunol 12: 763–773.

[2]Kil et al. 2012. Blood 119: 3744-3756.

[3]Whyburn et al. 2003. J Immunol 171: 1850-1858.

[4]Haselmayer, et. Al. 2019. J Immunol 202: 2888-2906.

Disclosure of Interests:

DANIEL ROBBINS Shareholder of: Nurix therapeutics, Employee of: Nurix therapeutics, Mark Noviski Shareholder of: Nurix Therapeutics, Employee of: Nurix Therapeutics, May Tan Shareholder of: Nurix Therapeutics, Employee of: Nurix Therapeutics, Cristiana Guiducci Shareholder of: Nurix Therapeutics, Employee of: Nurix Therapeutics, Timothy Ingallinera Shareholder of: Nurix Therapeutics, Employee of: Nurix Therapeutics, Dane Karr Shareholder of: Nurix Therapeutics, Employee of: Nurix Therapeutics, Aileen Kelly Shareholder of: Nurix Therapeutics, Employee of: Nurix Therapeutics, Zef Konst Shareholder of: Nurix Therapeutics, Employee of: Nurix Therapeutics, Austin Tenn-McClellan Shareholder of: Nurix Therapeutics, Employee of: Nurix Therapeutics, Jenny McKinnell Shareholder of: Nurix Therapeutics, Employee of: Nurix Therapeutics, Luz Perez Employee of: Nurix Therapeutics, Gwenn Hansen Shareholder of: Nurix Therapeutics, Employee of: Nurix Therapeutics, Ryan Rountree Shareholder of: Nurix Therapeutics, Employee of: Nurix Therapeutics

Peanut-induced anaphylaxis in children and adolescents: Data from the European Anaphylaxis Registry

BACKGROUND

Peanut allergy has a rising prevalence in high-income countries, affecting 0.5%-1.4% of children. This study aimed to better understand peanut anaphylaxis in comparison to anaphylaxis to other food triggers in European children and adolescents.

METHODS

Data was sourced from the European Anaphylaxis Registry via an online questionnaire, after in-depth review of food-induced anaphylaxis cases in a tertiary paediatric allergy centre.

RESULTS

3514 cases of food anaphylaxis were reported between July 2007 - March 2018, 56% in patients younger than 18 years. Peanut anaphylaxis was recorded in 459 children and adolescents (85% of all peanut anaphylaxis cases). Previous reactions (42% vs. 38%; p = .001), asthma comorbidity (47% vs. 35%; p < .001), relevant cofactors (29% vs. 22%; p = .004) and biphasic reactions (10% vs. 4%; p = .001) were more commonly reported in peanut anaphylaxis. Most cases were labelled as severe anaphylaxis (Ring&Messmer grade III 65% vs. 56% and grade IV 1.1% vs. 0.9%; p = .001). Self-administration of intramuscular adrenaline was low (17% vs. 15%), professional adrenaline administration was higher in non-peanut food anaphylaxis (34% vs. 26%; p = .003). Hospitalization was higher for peanut anaphylaxis (67% vs. 54%; p = .004).

CONCLUSIONS

The European Anaphylaxis Registry data confirmed peanut as one of the major causes of severe, potentially life-threatening allergic reactions in European children, with some characteristic features e.g., presence of asthma comorbidity and increased rate of biphasic reactions. Usage of intramuscular adrenaline as first-line treatment is low and needs to be improved. The Registry, designed as the largest database on anaphylaxis, allows continuous assessment of this condition.

Photovoice as a Participatory Research Tool in Amyotrophic Lateral Sclerosis

Background:

Photovoice is a qualitative research tool increasingly utilized in the healthcare field to understand the illness experience from the patient and caregiver perspective. This is the first study to evaluate photovoice in the context of amyotrophic lateral sclerosis (ALS).

Objective:

A patient and caregiver centered research tool was utilized to gain a greater understanding of challenges faced when living with ALS.

Methods:

Eight patients and three corresponding caregivers participating by taking photographs, writing descriptive text, and participating in individual and group interviews. Inductive thematic analysis was employed to uncover recurring themes.

Results:

Five main themes were identified; 1) facing the diagnosis, 2) loss of function, 3) isolation, 4) health system challenges, and 5) hope. Despite the devasting impact of ALS, the majority of participants reported a surprising amount of positivity in the face of receiving this difficult diagnosis, and demonstrated incredible creativity and adaptability to meet the ensuing loss of function. However, patients and caregivers discussed feelings of isolation and health care system challenges. The importance of hope was a strong and recurring theme.

Conclusions:

The photovoice research tool demonstrates the profound resilience of these participants, and challenges the medical community to find ways of fostering positivity and hope throughout the ALS disease course. Further clinic and community resources, education, and supports are needed to combat the sense of isolation and health care system challenges experienced by patients and their caregivers.

The World Brain Death Project: The More You Say It Does Not Make It True

The World Brain Death Project clarified many aspects of the diagnosis of brain death/death by neurologic criteria. Clearer descriptions than previously published were presented concerning the etiology, prerequisites, minimum clinical criteria, apnea testing targets, and indications for ancillary testing. Nevertheless, there remained many epistemic and metaphysical assertions that were either false, ad hoc, or confused. Epistemically, the project was not successful in explaining away remaining brain functions, complex reflexes as "spinal," the risk and lack of utility of the apnea test, the ignored and often present confounders of central endocrine dysfunction and high-cervical-spinal-cord injury, the limitations of ancillary tests, or the cases of reversibility of some findings of brain death/death by neurologic criteria. Metaphysically, the World Brain Death Project variously suggested different concepts of death that were not supported with argument. Concepts offered included simply restating the criterion of brain death/death by neurologic criteria; personhood, without recognizing it is a higher-brain concept; and emergent functions of the organism as a whole, without specifying what these might be, if not biologic anti-entropic integration that actually remains after brain death/death by neurologic criteria. The World Brain Death Project only offered confused metaphysical discussion, and gave no reason why the state they described as brain death/death by neurologic criteria should be considered death itself. The main epistemic and metaphysical problems with brain death/death by neurologic criteria remain untouched by the World Brain Death Project.

Optic Nerve Sheath Diameter in Preterm Infants: Suggested Values

OBJECTIVE

Timely detection of elevated intracranial pressure (ICP) in highrisk preterm infants may be critical to avoid permanent neurologic sequelae. Size of optic nerve sheath diameter (ONSD) is highly correlated with changes in ICP. Normal ultrasonographic ONSD values for preterm infants have been published. This study sought to compare these data with MRI measured OSND and to propose suggested ultrasonographic ONSD values.

METHODS

The ONSD in preterm MRIs were retrospectively measured and related to pre-existing ultrasonographic ONSD. Data were stratified for corrected gestational age. Simple linear regression between ONSD mean values and age was modeled for both eyes, and R2 was calculated. Suggested values for ultrasonographic ONSD were ascertained through linear regression and calculated prediction intervals.

RESULTS

ONSD measurements demonstrated R2 values of 0.95 (right ONSD MRI), 0.95 (left ONSD MRI), 0.96 (right ONSD ultrasound), and 0.93 (left ONSD ultrasound). Suggested ONSD values were incremental with corrected gestational age.

CONCLUSION

ONSD measurements with MRI and ultrasound are similar. The proposed suggested ONSD values may be helpful in clinical situations where ICPs are suspected or known.

Canada's Decentralized "Human-Driven" Approach During the Early COVID-19 Pandemic

A country's early response to a pandemic is critical for controlling the disease outbreak. During the COVID-19 pandemic, a number of southeast Asian countries adopted centralized, coordinated, rapid, and comprehensive approaches that involved smart technology (the "techno-driven" approach). In comparison, Canada's approach appeared to be decentralized, uncoordinated, and slow, and it focused on educating citizens and enhancing social and human capital (the "human-driven" approach). We propose that in future pandemics, early and coordinated "techno-driven" approaches should receive more careful consideration to curtail outbreaks; however, these approaches must be balanced with protecting individuals' freedoms.

Cytokine levels in children and adults with wheezing and asthma show specific patterns of variability over time

Levels of cytokines are used for in-depth characterization of patients with asthma; however, the variability over time might be a critical confounder. To analyze the course of serum cytokines in children, adolescents and adults with asthma and in healthy controls and to propose statistical methods to control for seasonal effects. Of 532 screened subjects, 514 (91·5%) were included in the All Age Asthma Cohort (ALLIANCE). The cohort included 279 children with either recurrent wheezing bronchitis (more than two episodes) or doctor-diagnosed asthma, 75 healthy controls, 150 adult asthmatics and 31 adult healthy controls. Blood samples were collected and 25 μl serum was used for analysis with the Bio-Plex Pr human cytokine 27-Plex assay. Mean age, body mass index and gender in the three groups of wheezers, asthmatic children and adult asthmatics were comparable to healthy controls. Wheezers (34·5%), asthmatic children (78·7%) and adult asthmatics (62·8%) were significantly more often sensitized compared to controls (4·5, 22 and 22·6%, respectively). Considering the entire cohort, interleukin (IL)-1ra, IL-4, IL-9, IL-17, macrophage inflammatory protein (MIP)-1- α and tumor necrosis factor (TNF)- α showed seasonal variability, whereas IL-1β, IL-7, IL-8, IL-13, eotaxin, granulocyte colony-stimulating factor (G-CSF), interferon gamma-induced protein (IP)-10, MIP-1 β and platelet-derived growth factor (PDGF)-BB did not. Significant differences between wheezers/asthmatics and healthy controls were observed for IL-17 and PDGF-BB, which remained stable after adjustment for the seasonality of IL-17. Seasonality has a significant impact on serum cytokine levels in patients with asthma. Because endotyping has achieved clinical importance to guide individualized patient-tailored therapy, it is important to account for seasonal effects.

Automated Device for Uncapping Multiple-Size Bioanalytical Sample Tubes Designed to Reduce Technician Strain and Increase Productivity

Technicians in a commercial laboratory manually uncap up to 700 sample tubes daily in preparation for bioanalytical testing. Manually twisting off sample tube caps not only is a time-consuming task, but also poses increased risk for muscle fatigue and repetitive-motion injuries. An automated device capable of uncapping sample tubes at a rate faster than the current workflow would be valuable for minimizing strain on technicians' hands and saving time. Although several commercial sample tube-uncapping products exist, they are not always usable for a workload that uses a mix of tube sizes and specific workflow. A functioning uncapping device was developed that can semi-automatically uncap sample tubes with three different heights and diameters and was compatible with the workflow in a commercial laboratory setting. Under limited testing, the average success rate with uncapping each of the three sample tube sizes or a mix of them was 90% or more, more than three times faster than manual uncapping, and met standard acceptance criteria using mass spectrometry. Our device with its current performance is still a prototype, requiring further development. It showed promise for ergonomic benefit to the laboratory technicians, however, reducing the necessity to manually unscrew caps.

Rare cause of emergency in the first week of life: congenital hepatoblastoma (case report)

During the first week of life, a sudden deterioration in a newborn commonly includes investigations to rule out infections, lung pathologies, cardiac lesions, neurological insults, metabolic disorders or gastrointestinal emergencies. It is unusual, however, to consider malignancy as the primary causative factor. In this case report, we describe a rare and unusual presentation of congenital hepatoblastoma, its complications and management in a neonate with multi-organ dysfunction. A term infant presented with sudden deterioration, hemodynamic instability and an acute abdomen on his 4th day of life. Surgical exploration revealed a ruptured neoplasm that pathology diagnosed as a congenital hepatoblastoma. After the patient was stabilized, chemotherapy was initiated. At present, the patient is 8 months old and under continuous follow-up of oncology service. This case highlights the importance of considering rare diagnoses including congenital malignancy when investigating and managing a sick newborn with multi-organ dysfunction.

Noninvasive ventilation for pediatric interfacility transports: a retrospective study

BACKGROUND

To characterize pediatric patients supported with continuous positive airway pressure and bilevel positive airway pressure (CPAP/BiPAP) or high-flow nasal cannula (HFNC) during interfacility transport (IFT).

METHODS

A retrospective study with a provincial pediatric transport team from a tertiary hospital pediatric intensive care unit. Pediatric patients aged 28 days to < 17 years, who required IFT between January 2017 and December 2018, were identified through a transport registry and were included in the study.

RESULTS

A total of 118 (26.7%) patients received CPAP/BIPAP or HFNC support for IFT. The most common respiratory diagnosis was bronchiolitis (46%). These patients were placed on respiratory support, 31.4 minutes after the transport team's arrival. None required intubation during their IFT, despite mean transport times of 163 minutes.

CONCLUSIONS

This study may provide important information for programs with large catchment areas, in which large distances and transport times should not be barriers to NIV implementation.

Brain Death Criteria: Medical Dogma and Outliers

The diagnosis of brain death (BD) is legally and medically accepted. Recently, several high-profile cases have led to discussions regarding the integrity of current criteria, and many physiologic problems have been identified to support the necessity for their reevaluation. These include a global variability of the criteria, the suggestion of a clinical "hierarchy," and the resultant approximation of BD. Further ambiguity has been exposed through case reports of reversible BD, and an inconsistent understanding from physicians who are viewed as experts in this domain. Meeting BD criteria clearly does not equate to a physiologic "death" of the brain, and a greater community perspective should be considered as the dialogue moves forward.

Impact of intensive care unit supportive care on the physiology of Ebola virus disease in a universally lethal non-human primate model

Background

There are currently limited data for the use of specific antiviral therapies for the treatment of Ebola virus disease (EVD). While there is anecdotal evidence that supportive care may be effective, there is a paucity of direct experimental data to demonstrate a role for supportive care in EVD. We studied the impact of ICU-level supportive care interventions including fluid resuscitation, vasoactive medications, blood transfusion, hydrocortisone, and ventilator support on the pathophysiology of EVD in rhesus macaques infected with a universally lethal dose of Ebola virus strain Makona C07.

Methods

Four NHPs were infected with a universally lethal dose Ebola virus strain Makona, in accordance with the gold standard lethal Ebola NHP challenge model. Following infection, the following therapeutic interventions were employed: continuous bedside supportive care, ventilator support, judicious fluid resuscitation, vasoactive medications, blood transfusion, and hydrocortisone as needed to treat cardiovascular compromise. A range of physiological parameters were continuously monitored to gage any response to the interventions.

Results

All four NHPs developed EVD and demonstrated a similar clinical course. All animals reached a terminal endpoint, which occurred at an average time of 166.5 ± 14.8 h post-infection. Fluid administration may have temporarily blunted a rise in lactate, but the effect was short lived. Vasoactive medications resulted in short-lived improvements in mean arterial pressure. Blood transfusion and hydrocortisone did not appear to have a significant positive impact on the course of the disease.

Conclusions

The model employed for this study is reflective of an intramuscular infection in humans (e.g., needle stick) and is highly lethal to NHPs. Using this model, we found that the animals developed progressive severe organ dysfunction and profound shock preceding death. While the overall impact of supportive care on the observed pathophysiology was limited, we did observe some time-dependent positive responses. Since this model is highly lethal, it does not reflect the full spectrum of human EVD. Our findings support the need for continued development of animal models that replicate the spectrum of human disease as well as ongoing development of anti-Ebola therapies to complement supportive care.

Electronic supplementary material

The online version of this article (10.1186/s40635-019-0268-8) contains supplementary material, which is available to authorized users.

Prehospital Management of Acute Stroke in Rural versus Urban Responders

Objective:

Stroke guideline compliance of rural Canadian prehospital emergency medical services (EMS) care in acute stroke is unknown. In this quality assurance study, we sought to compare rural and urban care by prehospital EMS evaluation/management indicators from patients assessed at an urban Canadian stroke center.

Materials and Methods:

One hundred adult patients were randomly selected from the stroke registry. Patients were transported through Rural EMS bypass protocols or urban EMS protocols (both bypass and direct) to our stroke center between January and December 2013. Patients were excluded if they were first evaluated at any other health center. Prehospital care was assessed using ten indicators for EMS evaluation/management, as recommended by acute stroke guidelines.

Results:

Compliance with acute stroke EMS evaluation/management indicators were statistically similar for both groups, except administrating a prehospital diagnostic tool (rural 31.8 vs. urban 70.3%; P = 0.002). Unlike urban EMS, rural EMS did not routinely document scene time.

Conclusion:

Rural EMS responders’ compliance to prehospital stroke evaluation/management was similar to urban EMS responders. Growth areas for both groups may be with prehospital stroke diagnostic tool utilization, whereas rural EMS responders may also improve with scene time documentation.

Pediatric early warning score and deteriorating ward patients on high-flow therapy

BACKGROUND

Delivery of non-invasive ventilation commonly occurs in the pediatric intensive care unit (PICU). With the advent of high-flow nasal cannula (HFNC), patients with respiratory distress may be rescued on the ward without a PICU admission. We evaluated our ward HFNC algorithm to determine its safety profile and independent predictors for non-responders, defined as requiring subsequent PICU admission.

METHODS

A retrospective chart review of patients <17 years of age admitted with respiratory distress between 2016 and 2017 was carried out. Pediatric Early Warning System (PEWS) respiratory score was used to assess the clinical response of patients requiring HFNC. Variables associated with non-responders were evaluated, and their PICU admission was studied for escalation of care and criticality.

RESULTS

Patients with comorbidities (P = 0.02) were more likely to require HFNC. Of the 18 patients initiated on HFNC, 44% (n = 8) remained on the ward. Non-responders (n = 10; 56%) had higher (2.7 vs 1.8; P = 0.03) and worsening (-0.1 vs 0.3; P = 0.05) PEWS respiratory scores 90 min after HFNC initiation. Eighty percent (n = 8) of non-responders required escalation to continuous positive airway pressure or bilevel positive airway pressure in the PICU. For both HFNC responders and non-responders, there were no requirements for intubation, evidence of air leak or difference in days of respiratory support.

CONCLUSIONS

High and worsening PEWS scores 90 min after HFNC initiation may indicate non-response when coupled with a standardized ward HFNC algorithm for respiratory distress. Further improvements may be seen with an earlier initiation of HFNC in the emergency department and more aggressive flow escalation on the ward.

Prospective surveillance of bacterial colonization and primary sepsis: findings of a tertiary neonatal intensive and intermediate care unit

BACKGROUND

Preterm infants and critically ill neonates are predisposed to nosocomial infections as sepsis. Moreover, these infants acquire commensal bacteria, which might become potentially harmful. On-ward transmission of these bacteria can cause outbreaks.

AIM

To report the findings of a prospective surveillance of bacterial colonization and primary sepsis in preterm infants and neonates.

METHODS

The results of the surveillance of bacterial colonization of the gut and the respiratory tract, targeting meticillin-resistant Staphylococcus aureus (MRSA), vancomycin-resistant enterococci (VRE) and Gram-negative bacteria from November 2016 to March 2018 were analysed. Bacterial colonization was compared to surveillance of sepsis.

FINDINGS

Six-hundred and seventy-one patients were admitted and 87.0 % (N=584) of the patients were screened; 48.3% (N=282) of the patients screened were colonized with at least one of the bacteria included in the screening; 26.2% of them (N=74) had multi-drug-resistant strains. A total of 534 bacterial isolates were found. The most frequently found species were Escherichia coli, Enterobacter cloacae, Klebsiella oxytoca and Klebsiella pneumoniae. Three MRSA but no VRE were detected. The surveillance detected a K. pneumoniae cluster involving nine patients. There were 23 blood-culture-confirmed sepsis episodes; 60.9% (N=14) were caused by staphylococci. Gram-negative bacteria (one Klebsiella aerogenes and two E. cloacae) caused three sepsis episodes which were preceded by colonization with the respective isolates.

CONCLUSIONS

Surveillance of colonization provided a comprehensive overview of species and antibiotic resistance patterns. It allowed early detection of a colonization cluster. Knowledge of colonization and surveillance of sepsis is useful for guiding infection control measures and antibiotic treatment.

Optic Nerve Sheath Diameter for Preterm Infants: A Pilot Study

OBJECTIVE

In preterm infants, early diagnosis and management of a raised intracranial pressure (ICP) may be important to improve neurodevelopmental outcomes. While invasive ICP monitoring is not recommended, ultrasonography of the optic nerve sheath diameter (ONSD) could provide a noninvasive alternative to evaluate ICP. The objective of this pilot study was to document ranges of ONSD in preterm infants.

METHODS

This prospective cohort pilot evaluated preterm infants who were admitted to the neonatal intensive care unit without suspected raised ICP. Three images per eye were obtained from a 20-5 MHz linear array ultrasound transducer placed on the patient's superior eyelid. The OSND was measured 3 mm behind the globe. A second ultrasonographer duplicated half of the scans. Multiple linear regression analysis was conducted for both right and left ONSD with corrected gestational age, weight, and head circumference as predictors. Lin's concordance assessed interrater reliability.

RESULTS

In 12 preterm infants 114 scans were performed on both eyes. The median age was 33 weeks (corrected gestational age) with a range of 29-36 weeks. Corrected gestational age was the strongest predictor for ONSD, and preliminary measurements at each gestational age were established. Interrater reliability demonstrated substantial agreement (Qc = 0.97).

CONCLUSION

In preterm infants, ONSD strongly correlates with corrected gestational age. These data should be validated with other imaging modalities before abnormal ranges can be considered.

Thoracic electrical impedance tomography to minimize right heart strain following cardiac arrest

Titrating ventilator settings to minimize pulmonary arterial pressures and optimize both ventilation and oxygen delivery can be challenging following cardiac arrest. Erroneous ventilator adjustments can lead to unnecessary strain on the right ventricle that may be particularly vulnerable during the acute recovery. We report a child with fulminant myocarditis who was mechanically ventilated using thoracic electrical impedance tomography to optimize regional lung inflation and possibly curtail right ventricular afterload following cardiac arrest.

Pulmonary Thromboses in Pediatric Acute Respiratory Distress Syndrome

Pediatric ARDS continues to be a management challenge in the ICU with prolonged hospitalizations and high mortality. Thromboembolic pulmonary embolism and in situ pulmonary artery thrombosis might represent underappreciated thrombotic processes for a subset of these patients. Although well described in the adult literature, descriptions of pulmonary thromboses with pediatric ARDS are limited to case reports. However, many risk factors for pulmonary thromboses are present in children with ARDS (eg, coagulopathy, endothelial injury, central venous catheters, concomitant inflammatory diseases), suggesting a much higher incidence is plausible. Based on an interpretation of animal, pediatric, and adult data, we propose a diagnostic algorithm to facilitate a timely and accurate diagnosis. Observing an alveolar dead space fraction ≥ 0.25, or either a 50% increase in physiologic dead space/tidal volume or a central venous saturation ≤ 60% over 24 h, triggers the algorithm. Together with targeted heparin treatment and right ventricular afterload reduction, clinical outcomes might improve if this particular patient subgroup can be identified early. While anticoagulation is recommended in adults with confirmed pulmonary embolism and low early mortality risk, data for children are limited.

Survey of Nutrition Practice in Patients with Severe Sepsis among Canadian Registered Dietitians

PURPOSE

The purpose of this study was to determine the opinions and reported nutrition practices of Canadian Registered Dietitians (RDs) with regard to feeding patients with severe sepsis.

METHODS

In 2017, surveys were sent to 112 eligible Canadian RDs in 10 provinces who were practicing in an intensive care environment. The survey included embedded branching logic questions developed to address major facets of sepsis, critical illness, and nutrition. The survey instrument assimilated all data in an anonymous manner, so respondents could not be linked to their answers.

RESULTS

Of the 64 RDs who responded (57% response rate), the majority practiced in adult intensive care (81%), within an academic center (59%), and in a mixed unit (73%). A wide variability of Canadian RDs' opinions and practice was reported in determining energy requirements, enteral nutrition (EN) practice, EN with vasoactive agents, parenteral nutrition (PN), and supplemental micronutrients.

CONCLUSIONS

Practice variability of Canadian RDs likely reflects gaps in both evidence and guidelines for severe sepsis. Further research efforts are needed to customize nutritional requirements in the patient with evolving sepsis, EN with patients at high risk for gastrointestinal dysfunction, optimizing PN, and the role of micronutrients.

Patient perspectives on transitioning to amyotrophic lateral sclerosis multidisciplinary clinics

Purpose

Multidisciplinary clinics (MDC) have become the standard of care for management of amyotrophic lateral sclerosis (ALS). No studies however, have captured patients’ perspectives during a transition to ALS MDCs. Recently, an ALS MDC emerged from a single-physician clinic in Saskatoon, Canada, providing patients with a unique exposure to two different models of care.

Patients and methods

Fifteen patients with ALS participated in semi-structured interviews that were digitally recorded and transcribed. Two independent researchers performed an inductive thematic analysis. Information was coded based on emerging and a priori themes. An iterative process followed involving discussion and reexamination of the themes until consensus was reached.

Results

All patients cited the convenience of integrated care as an advantage. Other advantages included clinical expertise and advocacy potential. Travel and reduced mobility were the most commonly discussed barriers/disadvantages of MDC attendance. The impact of geography and weather appeared to augment both the appreciation of an integrated approach and the impediment of travel, compared to the existing literature. The need for individualized care was demonstrated by the conflicting viewpoints obtained from participants. Most patients felt additional practitioners and supports for both patients and caregivers were required.

Conclusion

ALS patients transitioned to MDCs reported many of the advantages and disadvantages reported elsewhere. A novel perspective of a MDC’s advocacy potential was recognized, and the need for an innovative approach to meet demands for individualized care was highlighted.