1
|
Hodgson E, Briatico D, Klapman S, Skarsgard E, Beltempo M, Shah PS, Huisman E, Walton JM, Livingston MH. Association of Exclusive Breast Milk Intake and Outcomes in Infants With Uncomplicated Gastroschisis: A National Cohort Study. J Pediatr Surg 2024; 59:863-868. [PMID: 38413262 DOI: 10.1016/j.jpedsurg.2024.01.045] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/14/2024] [Accepted: 01/22/2024] [Indexed: 02/29/2024]
Abstract
BACKGROUND Enteral feeding is an essential part of the management of infants with gastroschisis. We hypothesized that exclusive breast milk is associated with improved neonatal outcomes. METHODS We conducted a retrospective review of infants with uncomplicated gastroschisis through the Canadian Pediatric Surgery Network (CAPSNet) and Canadian Neonatal Network (CNN). The primary outcome was time to full enteral feeds. RESULTS We identified 411 infants with gastroschisis treated at CAPSNet centres from 2014 to 2022. 144 patients were excluded due to gestational age <32 weeks, birth weight <1500 g, other congenital anomalies, or complicated gastroschisis. Of the remaining 267 participants, 78% (n = 209) received exclusive breast milk diet in the first 28 days of life, whereas 22% (n = 58) received supplemental or exclusive formula. Infants who received exclusive breast milk experienced higher time to reach full enteral feeding (median 24 vs 22 days, p = 0.047) but were more likely to have undergone delayed abdominal closure (32% vs 17%, p = 0.03). After adjustment, there were no significant differences between groups in time to reach full enteral feeds, duration of parenteral nutrition, or length of stay. Infants who received supplemental or exclusive formula had a similar risk of necrotizing enterocolitis (4% vs 3%) but were less likely to transition to exclusive breast milk at discharge (73% vs 11%, p < 0.001). CONCLUSION Early use of exclusive breast milk in infants with uncomplicated gastroschisis is associated with similar outcomes compared to supplemental or exclusive formula. Patients who received supplemental or exclusive formula were unlikely to transition to exclusive breastfeeding by discharge. LEVEL OF EVIDENCE Level IIb (Individual Cohort Study).
Collapse
Affiliation(s)
- Emily Hodgson
- Division of General Surgery, McMaster University, Hamilton, Canada
| | - Daniel Briatico
- McMaster Pediatric Surgery Research Collaborative, McMaster University, Hamilton, Canada; Michael G. DeGroote School of Medicine, McMaster University, Hamilton, Canada
| | - Sarah Klapman
- Michael G. DeGroote School of Medicine, McMaster University, Hamilton, Canada
| | - Erik Skarsgard
- Division of Pediatric Surgery, University of British Columbia, Vancouver, Canada
| | - Marc Beltempo
- Division of Neonatology, McGill University Health Centre, Montreal, Canada
| | - Prakesh S Shah
- Department of Pediatrics, Mount Sinai Hospital and University of Toronto, Toronto, Canada
| | - Esther Huisman
- Division of Neonatology, McMaster University, Hamilton, Canada
| | - J Mark Walton
- McMaster Pediatric Surgery Research Collaborative, McMaster University, Hamilton, Canada; Division of Pediatric Surgery, McMaster University, Hamilton, Canada
| | - Michael H Livingston
- McMaster Pediatric Surgery Research Collaborative, McMaster University, Hamilton, Canada; Division of Pediatric Surgery, McMaster University, Hamilton, Canada.
| |
Collapse
|
2
|
Archer VA, Samiee-Zafarghandy S, Farrokyhar F, Briatico D, Braga LH, Walton JM. Intravenous acetaminophen for postoperative pain in the neonatal intensive care unit: A protocol for a pilot randomized controlled trial (IVA POP). PLoS One 2023; 18:e0294519. [PMID: 37983228 PMCID: PMC10659208 DOI: 10.1371/journal.pone.0294519] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2023] [Accepted: 10/20/2023] [Indexed: 11/22/2023] Open
Abstract
BACKGROUND In neonates, uncontrolled pain and opioid exposure are both correlated with short- and long-term adverse events. Therefore, managing pain using opioid-sparing approaches is critical in neonatal populations. Multimodal pain control offers the opportunity to manage pain while reducing short- and long-term opioid-related adverse events. Intravenous (IV) acetaminophen may represent an appropriate adjunct to opioid-based postoperative pain control regimes. However, no trials assess this drug in patients less than 36 weeks post-conceptual age or weighing less than 1500 g. OBJECTIVE The proposed study aims to determine the feasibility of conducting a randomized control trial to compare IV acetaminophen and fentanyl to a saline placebo and fentanyl for patients admitted to the neonatal intensive care unit (NICU) undergoing major abdominal or thoracic surgery. METHODS AND DESIGN This protocol is for a single-centre, external pilot randomized controlled trial (RCT). Infants in the NICU who have undergone major thoracic or abdominal surgery will be enrolled. Sixty participants will undergo 1:1 randomization to receive intravenous acetaminophen and fentanyl or saline placebo and fentanyl. After surgery, IV acetaminophen or placebo will be given routinely for eight days (192 hours). Appropriate dosing will be determined based on the participant's gestational age. Patients will be followed for eight days after surgery and will undergo a chart review at 90 days. Primarily feasibility outcomes include recruitment rate, follow-up rate, compliance, and blinding index. Secondary clinical outcomes will be collected as well. CONCLUSION This external pilot RCT will assess the feasibility of performing a multicenter RCT comparing IV acetaminophen and fentanyl to a saline placebo and fentanyl in NICU patients following major abdominal and thoracic surgery. The results will inform the design of a multicenter RCT, which will have the appropriate power to determine the efficacy of this treatment. TRIAL REGISTRATION ClinicalTrials.gov NCT05678244, Registered December 6, 2022.
Collapse
Affiliation(s)
- Victoria Anne Archer
- Division of General Surgery, Department of Surgery, McMaster University, Hamilton, ON, Canada
| | | | | | - Daniel Briatico
- Department of Surgery, McMaster University, Hamilton, ON, Canada
| | - Luis H. Braga
- Division of Urology, McMaster University, Hamilton, ON, Canada
| | - J. Mark Walton
- Division of Pediatric General Surgery, Department of Surgery, McMaster University, Hamilton, ON, Canada
| |
Collapse
|
3
|
Hodgson EC, Livingston MH, Robinson T, Farrokhyar F, Walton JM. Use of breast milk in infants with uncomplicated gastroschisis: A retrospective cohort study. J Pediatr Surg 2022; 57:840-845. [PMID: 35058060 DOI: 10.1016/j.jpedsurg.2021.12.045] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/28/2021] [Accepted: 12/30/2021] [Indexed: 10/19/2022]
Abstract
BACKGROUND Infants with gastroschisis often experience slow return of bowel function following closure. The purpose of this study was to determine whether exclusive breast milk is associated with decreased time to enteral autonomy. METHODS We conducted a retrospective cohort study of infants with uncomplicated gastroschisis from a tertiary pediatric hospital. The primary outcome was enteral autonomy, defined as days from initiating enteral feeds to stopping parenteral nutrition. Secondary outcomes included days of parenteral nutrition, length of stay, positive culture, necrotizing enterocolitis, cholestasis, additional surgery, readmission, and mortality. RESULTS We identified 100 infants with gastroschisis treated from 2005 to 2019. Twenty-five were excluded due to gestational age <32 weeks, birth weight <1500 g, or gastroschisis-associated complications (e.g., intestinal atresia). Seventy-five were included in the analysis. Mean gestational age was 36 weeks, 48% were female, and all were diagnosed antenatally. Sixty-five infants (87%) received exclusive maternal (n = 64) or donor (n = 1) breast milk, while 10 others (13%) were fed formula for 1-16 days (mean 7 days). Two infants received formula only. Demographics and gastroschisis prognostic scores were similar between groups. Infants who were given breast milk exclusively demonstrated decreased time to enteral autonomy (median 18 versus 25 days, p = 0.023) and shorter duration of parenteral nutrition (median 20 versus 26 days, p = 0.037). CONCLUSION Exclusive breast milk may be associated with improved outcomes among infants with gastroschisis. Further research is needed to evaluate the economic impact of this association and explore possible confounders. These efforts may expand the role of donor breast milk for these patients.
Collapse
Affiliation(s)
- Emily C Hodgson
- Division of General Surgery, McMaster University, Hamilton, Canada; Biomedical Graduate Studies, University of Pennsylvania, Philadelphia, USA; Division of Pediatric General, Thoracic and Fetal Surgery, Children's Hospital of Philadelphia, Philadelphia, USA
| | - Michael H Livingston
- Division of Pediatric Surgery, McMaster University, Hamilton, Canada; McMaster Pediatric Surgery Research Collaborative, McMaster University, Hamilton, Canada
| | - Tessa Robinson
- Division of Pediatric Surgery, McMaster University, Hamilton, Canada; Department of Health Research Methods, Evidence & Impact, Faculty of Health Sciences, Hamilton, Canada
| | - Forough Farrokhyar
- Department of Health Research Methods, Evidence & Impact, Faculty of Health Sciences, Hamilton, Canada; Department of Surgery, McMaster University, Hamilton, Canada
| | - J Mark Walton
- Division of Pediatric Surgery, McMaster University, Hamilton, Canada; McMaster Pediatric Surgery Research Collaborative, McMaster University, Hamilton, Canada.
| |
Collapse
|
4
|
Kirupaharan S, Briatico D, Robinson T, Fitzgerald P, Walton JM. Postoperative management of pediatric patients undergoing minimally invasive repair of pectus excavatum: Where are we now? J Pediatr Surg 2022; 57:927-931. [PMID: 35058061 DOI: 10.1016/j.jpedsurg.2021.12.049] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/19/2021] [Accepted: 12/30/2021] [Indexed: 11/25/2022]
Abstract
PURPOSE Minimally invasive repair of pectus excavatum (MIRPE) often leads to a painful and challenging recovery period. This study aims to describe the postoperative management of pediatric patients undergoing MIRPE and compare postoperative outcomes between patients using different routes of postoperative analgesia. METHODS Retrospective chart review of pediatric patients who underwent MIRPE from July 2003 to September 2019 at a single pediatric tertiary care center. Data on pain management and course of hospital stay were ascertained. Descriptive statistics, Mann-Whitney U and Pearson Chi-Square tests were used to analyze data. A p-value <0.05 was considered significant. RESULTS Of the 115 patients identified, 58 (50.4%) managed pain postoperatively using thoracic epidural and 57 (49.6%) used intravenous patient-controlled analgesia (IVPCA). The transition from the predominant use of epidural to IVPCA for MIRPE occurred between 2012 and 2013. Higher pain scores were reported by the IVPCA group at 6 h (p<0.001) and 12 h (p<0.001) postoperative. Patients using IVPCA had lower postoperative opioid consumption (p<0.001) and switched to oral opioids sooner than the epidural group (p<0.001). Fewer patients in the IVPCA group required urinary catheterization (p<0.001). Patients using IVPCA had a shorter hospital stay (4 days [IQR 4-5]) compared to the epidural group (5.5 [IQR 5-6]; p<0.001). Readmission was comparable at 3.48% in the total sample. CONCLUSION Patients using intravenous patient-controlled analgesia reported higher pain scores however, this route of analgesia was associated with shorter hospital stay. Prospective studies designed to address moderator variables are required to confirm findings and develop standardized recovery protocols.
Collapse
Affiliation(s)
- Sawmmiya Kirupaharan
- McMaster Pediatric Surgery Research Collaborative, McMaster University, Hamilton, ON, Canada
| | - Daniel Briatico
- McMaster Pediatric Surgery Research Collaborative, McMaster University, Hamilton, ON, Canada; Division of Pediatric General Surgery, Department of Surgery, McMaster University, Hamilton, ON, Canada
| | - Tessa Robinson
- Department of Health Research Methods, Evidence & Impact, Faculty of Health Sciences, McMaster University, Hamilton, ON, Canada
| | - Peter Fitzgerald
- McMaster Pediatric Surgery Research Collaborative, McMaster University, Hamilton, ON, Canada; Division of Pediatric General Surgery, Department of Surgery, McMaster University, Hamilton, ON, Canada; McMaster Children's Hospital, Hamilton, ON, Canada
| | - J Mark Walton
- McMaster Pediatric Surgery Research Collaborative, McMaster University, Hamilton, ON, Canada; Division of Pediatric General Surgery, Department of Surgery, McMaster University, Hamilton, ON, Canada; McMaster Children's Hospital, Hamilton, ON, Canada.
| |
Collapse
|
5
|
Burchard PR, Lay R, Ruffolo LI, Ramazani SN, Walton JM, Livingston MH. Glycerin Suppositories and Enemas in Premature Infants: A Meta-analysis. Pediatrics 2022; 149:185633. [PMID: 35332357 DOI: 10.1542/peds.2021-053413] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/26/2022] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND AND OBJECTIVES Premature infants are often given glycerin suppositories or enemas to facilitate meconium evacuation and the transition to enteral feeds. We reviewed the best-available evidence for the use of glycerin suppositories and enemas in premature infants. METHODS We searched MEDLINE, Embase, and Cochrane Central for randomized controlled trials (RCTs) of premature infants treated with glycerin suppositories or enemas through January 2022. Studies were screened and data extracted independently and in duplicate. We included RCTs of premature infants <32 weeks gestation and/or birth weight <1500 g who were treated with glycerin suppositories or enemas. Meta-analysis was performed using random effects and reported as relative risk or mean difference. RESULTS We identified 6 single-center, RCTs of 389 premature infants treated with glycerin suppositories (n = 207) or enemas (n = 182). Mortality rates ranged from 0% to 17%, and the meta-analysis revealed no differences between treatment groups (P = .86). Active treatment was associated with earlier meconium evacuation (mean, 1.5 days; 95% confidence interval, 3.0 to 0.01; P = .05) but not a faster time to enteral feeds (mean, 0.5 days; P = .48). We identified 1 ongoing trial with a target recruitment of 220 premature infants. The quality of evidence was very low to moderate because of inadequate statistical power and other methodologic issues. CONCLUSIONS The use of glycerin suppositories and enemas in premature infants is associated with earlier meconium evacuation, but the clinical significance of this finding is uncertain. Treatment has no definitive effects on mortality, necrotizing enterocolitis, or enteral feeds.
Collapse
Affiliation(s)
| | - Raymond Lay
- School of Medicine and Dentistry, University of Rochester, Rochester, New York
| | | | | | - J Mark Walton
- Division of Pediatric Surgery, McMaster University, Hamilton, Ontario, Canada
| | - Michael H Livingston
- Division of Pediatric Surgery, University of Rochester Medical Center, Rochester, New York.,Division of Pediatric Surgery, McMaster University, Hamilton, Ontario, Canada
| |
Collapse
|
6
|
Livingston MH, Walton JM, Cohen E, Arca MJ. Re: Pediatric empyemas-Has the pendulum swung too far? J Pediatr Surg 2021; 56:1258-1259. [PMID: 33388141 DOI: 10.1016/j.jpedsurg.2020.12.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/30/2020] [Accepted: 12/01/2020] [Indexed: 10/22/2022]
Affiliation(s)
- Michael H Livingston
- Golisano Children's Hospital, University of Rochester Medical Center, Rochester, NY, USA.
| | | | - Eyal Cohen
- The Hospital for Sick Children, Toronto, ON, Canada
| | - Marjorie J Arca
- Golisano Children's Hospital, University of Rochester Medical Center, Rochester, NY, USA
| |
Collapse
|
7
|
Livingston MH, Walton JM, Cohen E. Surgery for children with disabilities: not without risk. Dev Med Child Neurol 2021; 63:130. [PMID: 33230853 DOI: 10.1111/dmcn.14742] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/20/2020] [Accepted: 10/21/2020] [Indexed: 11/28/2022]
Affiliation(s)
- Michael H Livingston
- Division of Pediatric Surgery, University of Rochester Medical Center, Rochester, New York, USA
| | - J Mark Walton
- Division of Pediatric Surgery, McMaster University, Hamilton, Ontario, Canada
| | - Eyal Cohen
- Department of Pediatrics, University of Toronto, Toronto, Ontario, Canada
| |
Collapse
|
8
|
Duchesnay I, Livingston MH, VanHouwelingen L, Walton JM. Generalised urticaria following ingestion of a nickel-plated coin in a 4-year-old girl. BMJ Case Rep 2020; 13:13/9/e234601. [PMID: 32900721 DOI: 10.1136/bcr-2020-234601] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
We report the case of a 4-year-old girl who presented to the emergency department after ingestion of a nickel-plated coin. Abdominal radiographs confirmed the presence of a coin in her stomach but she was otherwise asymptomatic. She was discharged with assurances that the foreign body would pass spontaneously. The patient developed significant generalised urticaria the next day, which became progressively more severe. Her symptoms prompted endoscopic removal of the nickel-plated coin and a postoperative course of corticosteroids and antihistamine therapy. This is the first reported case of generalised urticaria secondary to ingestion of a coin with nickel plating only (2% nickel content overall). A review of similar cases is provided.
Collapse
Affiliation(s)
- Isabelle Duchesnay
- Division of General Surgery, McMaster University, Hamilton, Ontario, Canada
| | - Michael H Livingston
- Division of Pediatric Surgery, University of Rochester Medical Center, Rochester, New York, USA
| | - Lisa VanHouwelingen
- Division of Pediatric Surgery, McMaster University, Hamilton, Ontario, Canada
| | - J Mark Walton
- Division of Pediatric Surgery, McMaster University, Hamilton, Ontario, Canada
| |
Collapse
|
9
|
Affiliation(s)
- Colm McCarthy
- Departments of Surgery (McCarthy, Walton) and Medicine (Carayannopoulos), Faculty of Health Sciences, McMaster University, Hamilton, Ont.; Department of Orthopedics (McCarthy) Brigham and Women's Hospital, Boston, Mass.; Department of Pediatric Surgery (Walton) McMaster Children's Hospital, Hamilton, Ont
| | - Kallirroi Carayannopoulos
- Departments of Surgery (McCarthy, Walton) and Medicine (Carayannopoulos), Faculty of Health Sciences, McMaster University, Hamilton, Ont.; Department of Orthopedics (McCarthy) Brigham and Women's Hospital, Boston, Mass.; Department of Pediatric Surgery (Walton) McMaster Children's Hospital, Hamilton, Ont
| | - J Mark Walton
- Departments of Surgery (McCarthy, Walton) and Medicine (Carayannopoulos), Faculty of Health Sciences, McMaster University, Hamilton, Ont.; Department of Orthopedics (McCarthy) Brigham and Women's Hospital, Boston, Mass.; Department of Pediatric Surgery (Walton) McMaster Children's Hospital, Hamilton, Ont.
| |
Collapse
|
10
|
Archer V, Robinson T, Kattail D, Fitzgerald P, Walton JM. Postoperative pain control following minimally invasive correction of pectus excavatum in pediatric patients: A systematic review. J Pediatr Surg 2020; 55:805-810. [PMID: 32081359 DOI: 10.1016/j.jpedsurg.2020.01.023] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/10/2020] [Accepted: 01/25/2020] [Indexed: 10/25/2022]
Abstract
PURPOSE Surgery for pectus excavatum is associated with significant postoperative pain. The aim of this study was to summarize the current literature regarding postoperative pain control for pediatric patients undergoing minimally invasive repair of pectus excavatum (MIRPE). METHODS A systematic search of Medline, Embase, PubMed, CINAHL, Web of Science, and the Cochrane Library for randomized controlled trials (RCT) comparing methods of pain control in pediatric patients undergoing MIRPE was conducted. Studies were restricted to the English language. RESULTS After screening 1304 references, 9 randomized control trials (RCTs) enrolling 485 patients were included. The average age was 11.9 years (±3.1). Pain scores were decreased with ropivacaine compared to bupivacaine-based epidurals. In studies comparing ketamine to opioid based patient-controlled anesthesia (PCA) pumps, the results were variable. Intercostal and paravertebral nerve blocks had decreased pain scores in 75% of the studies compared to opioid-based PCA. Opioid consumption was decreased in 50% of the trials assessing ketamine-based infusions and 75% of the studies comparing intercostal and paravertebral nerve blocks. Nausea was decreased in several of the ketamine-based infusion and intercostal and paravertebral nerve block studies. CONCLUSION Ketamine-including infusions or paravertebral and intercostal nerve blocks may represent superior methods of postoperative pain control for MIRPE. Further work is needed to confirm results. LEVEL OF EVIDENCE 2A [1].
Collapse
Affiliation(s)
- Victoria Archer
- Division of General Surgery, Department of Surgery, McMaster University, Hamilton, Ontario, Canada
| | - Tessa Robinson
- Division of Pediatric General Surgery, Department of Surgery, McMaster University, Hamilton, Ontario, Canada; McMaster Pediatric Surgery Research Collaborative, Hamilton, Ontario, Canada
| | - Deepa Kattail
- Department of Anesthesia, McMaster University, Hamilton, Ontario, Canada; McMaster Children's Hospital, Hamilton, Ontario, Canada
| | - Peter Fitzgerald
- Division of Pediatric General Surgery, Department of Surgery, McMaster University, Hamilton, Ontario, Canada; McMaster Pediatric Surgery Research Collaborative, Hamilton, Ontario, Canada; McMaster Children's Hospital, Hamilton, Ontario, Canada
| | - J Mark Walton
- Division of Pediatric General Surgery, Department of Surgery, McMaster University, Hamilton, Ontario, Canada; McMaster Pediatric Surgery Research Collaborative, Hamilton, Ontario, Canada; McMaster Children's Hospital, Hamilton, Ontario, Canada.
| |
Collapse
|
11
|
Livingston MH, Mahant S, Connolly B, MacLusky I, Laberge S, Giglia L, Yang C, Roberts A, Shawyer A, Brindle M, Parsons S, Stoian C, Walton JM, Thorpe KE, Chen Y, Zuo F, Mamdani M, Chan C, Loong D, Isaranuwatchai W, Ratjen F, Cohen E. Effectiveness of Intrapleural Tissue Plasminogen Activator and Dornase Alfa vs Tissue Plasminogen Activator Alone in Children with Pleural Empyema: A Randomized Clinical Trial. JAMA Pediatr 2020; 174:332-340. [PMID: 32011642 PMCID: PMC7042898 DOI: 10.1001/jamapediatrics.2019.5863] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
IMPORTANCE Clinical guidelines recommend that children with pleural empyema be treated with chest tube insertion and intrapleural fibrinolytics. The addition of dornase alfa (DNase) has been reported to improve outcomes in adults but remains unproven in children. OBJECTIVE To determine if intrapleural tissue plasminogen activator (tPA) and DNase is more effective than tPA and placebo at reducing hospital length of stay in children with pleural empyema. DESIGN, SETTING, AND PARTICIPANTS This multicenter, parallel-group, placebo-controlled, superiority randomized clinical trial included children diagnosed as having pleural empyema requiring drainage aged 6 months to 18 years treated at 6 tertiary Canadian children's hospitals. A total of 379 children were assessed for eligibility; 281 were excluded and 98 were randomized. One child was excluded after randomization for not meeting the inclusion criteria. Data were collected from March 4, 2013, to December 13, 2017. INTERVENTIONS Participants underwent chest tube insertion and 3 daily administrations of intrapleural tPA, 4 mg, followed by DNase, 5 mg (intervention group), or 5 mL of normal saline (placebo; control group). Participants, families, clinical staff, and members of the study team were blinded to allocation. MAIN OUTCOMES AND MEASURES The primary outcome was hospital length of stay from chest tube insertion to discharge. Secondary outcomes included time to meeting discharge criteria, time to chest tube removal, mean fever duration, additional pleural drainage procedures, hospital readmissions, and total health care cost. RESULTS Of the 97 analyzed children with pleural empyema, 52 (54%) were male, and the mean (SD) age was 5.1 (3.6) years. A total of 49 children were randomized to tPA and DNase and 48 were randomized to tPA and placebo. Treatment with tPA and DNase was not associated with decreased hospital length of stay compared with tPA and placebo (mean [SD] length of stay, 9.0 [4.9] vs 9.1 [5.3] days; mean difference, -0.1 days; 95% CI, -2.0 to 2.1; P = .96). Similarly, no significant differences were observed for any of the secondary outcomes. Of the 14 adverse events in the tPA and DNase group, 6 (43%) were serious; of the 21 adverse events in the tPA and placebo group, 8 (38%) were serious. There were no deaths. CONCLUSIONS AND RELEVANCE The addition of DNase to intrapleural tPA for children with pleural empyema had no effect on hospital length of stay or other outcomes compared with tPA with placebo. Clinical practice guidelines should continue to support the use of chest tube insertion and intrapleural fibrinolytics alone as first-line treatment for pediatric empyema. TRIAL REGISTRATION ClinicalTrials.gov identifier: NCT01717742.
Collapse
Affiliation(s)
- Michael H. Livingston
- McMaster Children’s Hospital, McMaster University, Hamilton, Ontario, Canada,Golisano Children’s Hospital, University of Rochester Medical Center, Rochester, New York
| | - Sanjay Mahant
- Department of Pediatrics, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Bairbre Connolly
- Image-Guided Therapy, Department of Diagnostic Imaging, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Ian MacLusky
- Children’s Hospital of Eastern Ontario, University of Ottawa, Ottawa, Ontario, Canada
| | - Sophie Laberge
- Centre Hospitalier Universitaire Sainte-Justine, Université de Montréal, Montreal, Quebec, Canada
| | - Lucia Giglia
- McMaster Children’s Hospital, McMaster University, Hamilton, Ontario, Canada
| | - Connie Yang
- British Columbia’s Children’s Hospital, Division of Respiratory Medicine, Department of Pediatrics, University of British Columbia, Vancouver, British Columbia, Canada
| | - Ashley Roberts
- British Columbia’s Children’s Hospital, Division of Respiratory Medicine, Department of Pediatrics, University of British Columbia, Vancouver, British Columbia, Canada
| | - Anna Shawyer
- Health Sciences Centre, Winnipeg, Manitoba, Canada
| | - Mary Brindle
- Alberta Children’s Hospital, University of Calgary, Calgary, Alberta, Canada
| | - Simon Parsons
- Alberta Children’s Hospital, University of Calgary, Calgary, Alberta, Canada
| | - Cristina Stoian
- Alberta Children’s Hospital, University of Calgary, Calgary, Alberta, Canada
| | - J. Mark Walton
- McMaster Children’s Hospital, McMaster University, Hamilton, Ontario, Canada
| | - Kevin E. Thorpe
- Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada,Applied Health Research Centre, Li Ka Shing Knowledge Institute, St Michael’s Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Yang Chen
- Applied Health Research Centre, Li Ka Shing Knowledge Institute, St Michael’s Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Fei Zuo
- Applied Health Research Centre, Li Ka Shing Knowledge Institute, St Michael’s Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Muhammad Mamdani
- Li Ka Shing Centre for Healthcare Analytics Research and Training, St Michael’s Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Carol Chan
- Department of Pediatrics, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Desmond Loong
- Centre for Excellence in Economic Analysis Research (CLEAR), The HUB Health Research Solutions, St Michael’s Hospital, Toronto, Ontario, Canada,Li Ka Shing Knowledge Institute, St Michael’s Hospital, Toronto, Ontario, Canada
| | - Wanrudee Isaranuwatchai
- Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada,Centre for Excellence in Economic Analysis Research (CLEAR), The HUB Health Research Solutions, St Michael’s Hospital, Toronto, Ontario, Canada,Li Ka Shing Knowledge Institute, St Michael’s Hospital, Toronto, Ontario, Canada
| | - Felix Ratjen
- Department of Pediatrics, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Eyal Cohen
- Department of Pediatrics, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| |
Collapse
|
12
|
Livingston MH, Elliott T, Williams C, Jones SA, Rosenbaum PL, Walton JM. Glycerin suppositories used prophylactically in premature infants (supp): A pilot randomized controlled trial. J Neonatal Perinatal Med 2020; 13:495-505. [PMID: 32083593 DOI: 10.3233/npm-190310] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND Glycerin suppositories are often used to facilitate meconium evacuation in premature infants. The evidence for this practice is inconclusive. The purpose of this study was to assess the feasibility of a multicenter randomized controlled trial on the effectiveness of this treatment strategy. STUDY DESIGN We conducted an external pilot study for a multicenter randomized controlled trial of premature infants randomized to glycerin suppositories or placebo procedure. Participants were included if they were gestational age of 24 weeks 0 days to 31 weeks 6 days and/or birthweight of 500 to 1500 grams. We excluded infants with life-threatening congenital anomalies, contraindications to receiving suppositories, or signs of clinical instability. Outcomes included cost, recruitment, and treatment-related adverse events. RESULT A total of 109 were screened, 79 were initially eligible, and 34 consented to participate. Four of these infants were excluded prior to randomization due to thrombocytopenia, 30 were randomized, and 26 reached full enteral feeds. Three infants (10%) experienced rectal bleeding 5 to 43 days after completing study treatments. An anal fissure was noted in two of these patients. There were no cases of rectal perforation but one infant assigned to active treatment developed necrotizing enterocolitis. CONCLUSIONS Conducting a multicenter randomized controlled trial on the use of glycerin suppositories in premature infants is feasible. Minor modifications to the study protocol are needed to increase participant recruitment and simplify the administration of study treatments.
Collapse
Affiliation(s)
| | - T Elliott
- McMaster Pediatric Surgery Research Collaborative.,Division of Pediatric Surgery, McMaster University, Hamilton, ON, Canada
| | - C Williams
- Department of Pediatrics, McMaster University, Hamilton, ON, Canada.,Division of Neonatology, McMaster University, Hamilton, ON, Canada
| | - S A Jones
- Division of Pediatric Surgery, Western University, London, ON, Canada
| | - P L Rosenbaum
- Division of Neonatology, McMaster University, Hamilton, ON, Canada.,CanChild Center for Childhood Disability Research, McMaster University, Hamilton, ON, Canada
| | - J M Walton
- McMaster Pediatric Surgery Research Collaborative.,Division of Pediatric Surgery, McMaster University, Hamilton, ON, Canada
| |
Collapse
|
13
|
Chorley AG, Walton JM, Montesanto B, Chan TM. Developing Residents as Medical Educators via the McMaster Multidisciplinary Academic Day Planning Committee. Cureus 2019; 11:e5855. [PMID: 31754589 PMCID: PMC6830853 DOI: 10.7759/cureus.5855] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
Background Residents are being asked to perform educator roles such as curriculum design and learner assessment with minimal professional development in leadership or medical education. The Multidisciplinary Academic Day (MAD) planning committee is a resident-led initiative responsible for delivering combined educational half-day sessions and workshops for all residents at McMaster University. Objective We sought to determine the impact participation in MAD planning committee had on residents' professional development and career goals. Methods We conducted a program evaluation survey of 19 of 30 (63.3%) current and former committee members to determine how the MAD planning committee’s alumni perceived its usefulness, and how participation affected their professional development. Results Residents cited a desire to gain medical education experience, learn about event planning and management, and improve resident education as reasons for joining the committee; 89.5% of respondents felt they had met these goals. Experience on the committee included skills related to curriculum design, developing needs assessments and programmatic evaluation. Many residents felt it helped them acquire leadership skills such as decision-making, idea generation, delegation, and public speaking. Several noted that it had sparked an interest in medical education as part of an academic career, and one former member subsequently pursued a Master’s of Education. The majority of the respondents (78.9%) felt it was helpful for their careers and 94.7% would recommend this experience to others interested in leadership and medical education. Conclusion Involvement in the MAD planning committee is a highly useful way for residents to acquire leadership skills, develop an interest in medical education and work in a multidisciplinary team.
Collapse
Affiliation(s)
| | - J Mark Walton
- Pediatric Surgery, McMaster University, Hamilton, CAN
| | | | - Teresa M Chan
- Emergency Medicine, McMaster University, Hamilton, CAN
| |
Collapse
|
14
|
Fernandes AR, Elliott T, McInnis C, Easterbrook B, Walton JM. Evaluating complication rates and outcomes among infants less than 5kg undergoing traditional percutaneous endoscopic gastrostomy insertion: A retrospective chart review. J Pediatr Surg 2018; 53:933-936. [PMID: 29506815 DOI: 10.1016/j.jpedsurg.2018.02.017] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/12/2018] [Accepted: 02/01/2018] [Indexed: 02/07/2023]
Abstract
PURPOSE Percutaneous endoscopic gastrostomy (PEG) enables enteral nutrition for patients with inadequate oral intake. Laparoscopic guidance of PEG insertion is used for high-risk populations, including in infants less than 5kg at insertion. This study aimed to assess complication rates with traditional PEG tube insertion in infants less than 5kg at a single tertiary care center. METHODS A retrospective review of patients less than 5kg who underwent PEG insertion was conducted. PEG insertion-related complications, up to four years following insertion, were collected. Outcomes were reported as counts and percentages, or median with minimum and maximum values. RESULTS 480 pediatric gastrostomy procedures between January 1, 2009 and February 1, 2017, were screened, with 129 included for analysis. Median weight at PEG insertion was 3800g. Superficial surgical site infection (SSI) occurred in 6 (4.7%) patients, and 1 (0.8%) required readmission for intravenous antibiotics. One (0.8%) required endoscopic management for retained foreign body, 1 (0.8%) required operative management for gastrocolic fistula, and 1 (0.8%) for persistent gastrocutaneous fistula. No deep space SSI, procedure-related hemorrhage requiring readmission or transfusion, buried bumper syndrome, or procedure-related mortality occurred. CONCLUSION Traditional PEG tube insertion in infants less than 5kg results in complication rates comparable to pediatric literature standards. LEVEL OF EVIDENCE Level II, retrospective prognosis study.
Collapse
Affiliation(s)
| | - Tessa Elliott
- McMaster Pediatric Surgery Research Collaborative, Department of Surgery, McMaster University, Hamilton, Ontario, Canada
| | - Carter McInnis
- McMaster Pediatric Surgery Research Collaborative, Department of Surgery, McMaster University, Hamilton, Ontario, Canada
| | - Bethany Easterbrook
- McMaster Pediatric Surgery Research Collaborative, Department of Surgery, McMaster University, Hamilton, Ontario, Canada
| | - J Mark Walton
- McMaster Children's Hospital, Hamilton, Ontario, Canada; McMaster Pediatric Surgery Research Collaborative, Department of Surgery, McMaster University, Hamilton, Ontario, Canada.
| |
Collapse
|
15
|
Li C, Shanahan S, Livingston MH, Walton JM. Malone appendicostomy versus cecostomy tube insertion for children with intractable constipation: A systematic review and meta-analysis. J Pediatr Surg 2018. [PMID: 29519574 DOI: 10.1016/j.jpedsurg.2018.02.010] [Citation(s) in RCA: 32] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
PURPOSE Children with intractable constipation are often treated with antegrade continence enemas. This requires the creation of a Malone appendicostomy in the operating room or insertion of a cecostomy tube using endoscopic, radiologic, or surgical techniques. The purpose of this study was to assess the evidence regarding these procedures. METHODS We conducted a search of Embase, Medline, CINAHL, and Web of Science up to October 2016. We included comparative studies of children treated with Malone appendicostomy or cecostomy tube insertion. Two reviewers screened abstracts, reviewed studies, and extracted data. RESULTS We identified 166 children from three retrospective studies who underwent Malone appendicostomy (n=82) or cecostomy tube insertion (n=84). There were no differences in the number of patients who achieved continence (80% versus 70%, p=0.76), but the need for additional surgery was higher in children treated with Malone appendicostomy (30% versus 12%, p=0.01). Studies reported a variety of tube and stoma-related complications, but quality of life was not assessed using validated measures. CONCLUSION Malone appendicostomy and cecostomy tube insertion are comparable in terms of achieving continence. Children treated with Malone appendicostomy appear to be more likely to require additional surgery due to early or late complications. LEVEL OF EVIDENCE Therapeutic, 1c.
Collapse
Affiliation(s)
- Christine Li
- McMaster Pediatric Surgery Research Collaborative, McMaster University, Hamilton, Ontario, Canada
| | - Sara Shanahan
- McMaster Pediatric Surgery Research Collaborative, McMaster University, Hamilton, Ontario, Canada; Division of General Surgery, McMaster University, Hamilton, Ontario, Canada
| | - Michael H Livingston
- McMaster Pediatric Surgery Research Collaborative, McMaster University, Hamilton, Ontario, Canada; Division of Pediatric Surgery, McMaster University, Hamilton, Ontario, Canada
| | - J Mark Walton
- McMaster Pediatric Surgery Research Collaborative, McMaster University, Hamilton, Ontario, Canada; Division of Pediatric Surgery, McMaster University, Hamilton, Ontario, Canada.
| |
Collapse
|
16
|
Yardley S, Westerman M, Bartlett M, Walton JM, Smith J, Peile E. The do's, don't and don't knows of supporting transition to more independent practice. Perspect Med Educ 2018; 7:8-22. [PMID: 29383578 PMCID: PMC5807269 DOI: 10.1007/s40037-018-0403-3] [Citation(s) in RCA: 47] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/10/2023]
Abstract
INTRODUCTION Transitions are traditionally viewed as challenging for clinicians. Throughout medical career pathways, clinicians need to successfully navigate successive transitions as they become progressively more independent practitioners. In these guidelines, we aim to synthesize the evidence from the literature to provide guidance for supporting clinicians in their development of independence, and highlight areas for further research. METHODS Drawing upon D3 method guidance, four key themes universal to medical career transitions and progressive independence were identified by all authors through discussion and consensus from our own experience and expertise: workplace learning, independence and responsibility, mentoring and coaching, and patient perspectives. A scoping review of the literature was conducted using Medline database searches in addition to the authors' personal archives and reference snowballing searches. RESULTS 387 articles were identified and screened. 210 were excluded as not relevant to medical transitions (50 at title screen; 160 at abstract screen). 177 full-text articles were assessed for eligibility; a further 107 were rejected (97 did not include career transitions in their study design; 10 were review articles; the primary references of these were screened for inclusion). 70 articles were included of which 60 provided extractable data for the final qualitative synthesis. Across the four key themes, seven do's, two don'ts and seven don't knows were identified, and the strength of evidence was graded for each of these recommendations. CONCLUSION The two strongest messages arising from current literature are first, transitions should not be viewed as one moment in time: career trajectories are a continuum with valuable opportunities for personal and professional development throughout. Second, learning needs to be embedded in practice and learners provided with authentic and meaningful learning opportunities. In this paper, we propose evidence-based guidelines aimed at facilitating such transitions through the fostering of progressive independence.
Collapse
Affiliation(s)
- Sarah Yardley
- Central and North West London NHS Foundation Trust, London, UK.
| | | | | | - J Mark Walton
- McMaster Children's Hospital, Hamilton, Ontario, Canada
| | | | - Ed Peile
- St Catherine's College, Oxford, UK
| |
Collapse
|
17
|
Grierson LEM, Mercuri M, Brailovsky C, Cole G, Abrahams C, Archibald D, Bandiera G, Phillips SP, Stirrett G, Walton JM, Wong E, Schabort I. Admission factors associated with international medical graduate certification success: a collaborative retrospective review of postgraduate medical education programs in Ontario. CMAJ Open 2017; 5:E785-E790. [PMID: 29183879 PMCID: PMC5741432 DOI: 10.9778/cmajo.20170073] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND The failure rate on certification examinations of The College of Family Physicians of Canada (CFPC) and the Royal College of Physicians and Surgeons of Canada (RCPSC) is significantly higher for international medical graduates than for Canadian medical school graduates. The purpose of the current study was to generate evidence that supports or refutes the validity of hypotheses proposed to explain the lower success rates. METHODS We conducted retrospective analyses of admissions and certification data to determine the factors associated with success of international medical graduate residents on the certification examinations. International medical graduates who entered an Ontario residency program between 2005 and 2012 and had written a certification examination by the time of the analysis (2015) were included in the study. Data available at the time of admission for each resident, including demographic characteristics, previous experiences and previous professional experiences, were collected from each of the 6 Ontario medical schools and matched with certification examination results provided by The CFPC and the RCPSC. We developed logistic regression models to determine the association of each factor with success on the examinations. RESULTS Data for 900 residents were analyzed. The models revealed resident age to be strongly associated with performance across all examinations. Fluency in English, female sex and the Human Development Index value associated with the country of medical school training had differential associations across the examinations. INTERPRETATION The findings should contribute to an improved understanding of certification success by international medical graduates, help residency programs identify at-risk residents and underpin the development of specific educational and remedial interventions. In considering the results, it should be kept in mind that some variables are not amenable to changes in selection criteria.
Collapse
Affiliation(s)
- Lawrence E M Grierson
- Affiliations: Department of Family Medicine (Grierson, Mercuri, Schabort); Program for Educational Research and Development (Grierson); Division of Emergency Medicine (Mercuri); Division of Pediatric Surgery (Walton), McMaster University, Hamilton, Ont.; College of Family Physicians of Canada (Brailovsky), Mississauga, Ont.; Royal College of Physicians and Surgeons of Canada (Cole), Ottawa, Ont.; Post-MD Program (Abrahams, Bandiera), University of Toronto, Toronto, Ont.; Department of Family Medicine (Archibald), University of Ottawa, Ottawa, Ont.; Department of Family Medicine (Phillips), Queen's University, Kingston, Ont.; Department of Family Medicine (Stirrett), Northern Ontario School of Medicine, Sudbury, Ont.; Schulich School of Medicine & Dentistry (Wong), Western University, London, Ont
| | - Mathew Mercuri
- Affiliations: Department of Family Medicine (Grierson, Mercuri, Schabort); Program for Educational Research and Development (Grierson); Division of Emergency Medicine (Mercuri); Division of Pediatric Surgery (Walton), McMaster University, Hamilton, Ont.; College of Family Physicians of Canada (Brailovsky), Mississauga, Ont.; Royal College of Physicians and Surgeons of Canada (Cole), Ottawa, Ont.; Post-MD Program (Abrahams, Bandiera), University of Toronto, Toronto, Ont.; Department of Family Medicine (Archibald), University of Ottawa, Ottawa, Ont.; Department of Family Medicine (Phillips), Queen's University, Kingston, Ont.; Department of Family Medicine (Stirrett), Northern Ontario School of Medicine, Sudbury, Ont.; Schulich School of Medicine & Dentistry (Wong), Western University, London, Ont
| | - Carlos Brailovsky
- Affiliations: Department of Family Medicine (Grierson, Mercuri, Schabort); Program for Educational Research and Development (Grierson); Division of Emergency Medicine (Mercuri); Division of Pediatric Surgery (Walton), McMaster University, Hamilton, Ont.; College of Family Physicians of Canada (Brailovsky), Mississauga, Ont.; Royal College of Physicians and Surgeons of Canada (Cole), Ottawa, Ont.; Post-MD Program (Abrahams, Bandiera), University of Toronto, Toronto, Ont.; Department of Family Medicine (Archibald), University of Ottawa, Ottawa, Ont.; Department of Family Medicine (Phillips), Queen's University, Kingston, Ont.; Department of Family Medicine (Stirrett), Northern Ontario School of Medicine, Sudbury, Ont.; Schulich School of Medicine & Dentistry (Wong), Western University, London, Ont
| | - Gary Cole
- Affiliations: Department of Family Medicine (Grierson, Mercuri, Schabort); Program for Educational Research and Development (Grierson); Division of Emergency Medicine (Mercuri); Division of Pediatric Surgery (Walton), McMaster University, Hamilton, Ont.; College of Family Physicians of Canada (Brailovsky), Mississauga, Ont.; Royal College of Physicians and Surgeons of Canada (Cole), Ottawa, Ont.; Post-MD Program (Abrahams, Bandiera), University of Toronto, Toronto, Ont.; Department of Family Medicine (Archibald), University of Ottawa, Ottawa, Ont.; Department of Family Medicine (Phillips), Queen's University, Kingston, Ont.; Department of Family Medicine (Stirrett), Northern Ontario School of Medicine, Sudbury, Ont.; Schulich School of Medicine & Dentistry (Wong), Western University, London, Ont
| | - Caroline Abrahams
- Affiliations: Department of Family Medicine (Grierson, Mercuri, Schabort); Program for Educational Research and Development (Grierson); Division of Emergency Medicine (Mercuri); Division of Pediatric Surgery (Walton), McMaster University, Hamilton, Ont.; College of Family Physicians of Canada (Brailovsky), Mississauga, Ont.; Royal College of Physicians and Surgeons of Canada (Cole), Ottawa, Ont.; Post-MD Program (Abrahams, Bandiera), University of Toronto, Toronto, Ont.; Department of Family Medicine (Archibald), University of Ottawa, Ottawa, Ont.; Department of Family Medicine (Phillips), Queen's University, Kingston, Ont.; Department of Family Medicine (Stirrett), Northern Ontario School of Medicine, Sudbury, Ont.; Schulich School of Medicine & Dentistry (Wong), Western University, London, Ont
| | - Douglas Archibald
- Affiliations: Department of Family Medicine (Grierson, Mercuri, Schabort); Program for Educational Research and Development (Grierson); Division of Emergency Medicine (Mercuri); Division of Pediatric Surgery (Walton), McMaster University, Hamilton, Ont.; College of Family Physicians of Canada (Brailovsky), Mississauga, Ont.; Royal College of Physicians and Surgeons of Canada (Cole), Ottawa, Ont.; Post-MD Program (Abrahams, Bandiera), University of Toronto, Toronto, Ont.; Department of Family Medicine (Archibald), University of Ottawa, Ottawa, Ont.; Department of Family Medicine (Phillips), Queen's University, Kingston, Ont.; Department of Family Medicine (Stirrett), Northern Ontario School of Medicine, Sudbury, Ont.; Schulich School of Medicine & Dentistry (Wong), Western University, London, Ont
| | - Glen Bandiera
- Affiliations: Department of Family Medicine (Grierson, Mercuri, Schabort); Program for Educational Research and Development (Grierson); Division of Emergency Medicine (Mercuri); Division of Pediatric Surgery (Walton), McMaster University, Hamilton, Ont.; College of Family Physicians of Canada (Brailovsky), Mississauga, Ont.; Royal College of Physicians and Surgeons of Canada (Cole), Ottawa, Ont.; Post-MD Program (Abrahams, Bandiera), University of Toronto, Toronto, Ont.; Department of Family Medicine (Archibald), University of Ottawa, Ottawa, Ont.; Department of Family Medicine (Phillips), Queen's University, Kingston, Ont.; Department of Family Medicine (Stirrett), Northern Ontario School of Medicine, Sudbury, Ont.; Schulich School of Medicine & Dentistry (Wong), Western University, London, Ont
| | - Susan P Phillips
- Affiliations: Department of Family Medicine (Grierson, Mercuri, Schabort); Program for Educational Research and Development (Grierson); Division of Emergency Medicine (Mercuri); Division of Pediatric Surgery (Walton), McMaster University, Hamilton, Ont.; College of Family Physicians of Canada (Brailovsky), Mississauga, Ont.; Royal College of Physicians and Surgeons of Canada (Cole), Ottawa, Ont.; Post-MD Program (Abrahams, Bandiera), University of Toronto, Toronto, Ont.; Department of Family Medicine (Archibald), University of Ottawa, Ottawa, Ont.; Department of Family Medicine (Phillips), Queen's University, Kingston, Ont.; Department of Family Medicine (Stirrett), Northern Ontario School of Medicine, Sudbury, Ont.; Schulich School of Medicine & Dentistry (Wong), Western University, London, Ont
| | - Glenna Stirrett
- Affiliations: Department of Family Medicine (Grierson, Mercuri, Schabort); Program for Educational Research and Development (Grierson); Division of Emergency Medicine (Mercuri); Division of Pediatric Surgery (Walton), McMaster University, Hamilton, Ont.; College of Family Physicians of Canada (Brailovsky), Mississauga, Ont.; Royal College of Physicians and Surgeons of Canada (Cole), Ottawa, Ont.; Post-MD Program (Abrahams, Bandiera), University of Toronto, Toronto, Ont.; Department of Family Medicine (Archibald), University of Ottawa, Ottawa, Ont.; Department of Family Medicine (Phillips), Queen's University, Kingston, Ont.; Department of Family Medicine (Stirrett), Northern Ontario School of Medicine, Sudbury, Ont.; Schulich School of Medicine & Dentistry (Wong), Western University, London, Ont
| | - J Mark Walton
- Affiliations: Department of Family Medicine (Grierson, Mercuri, Schabort); Program for Educational Research and Development (Grierson); Division of Emergency Medicine (Mercuri); Division of Pediatric Surgery (Walton), McMaster University, Hamilton, Ont.; College of Family Physicians of Canada (Brailovsky), Mississauga, Ont.; Royal College of Physicians and Surgeons of Canada (Cole), Ottawa, Ont.; Post-MD Program (Abrahams, Bandiera), University of Toronto, Toronto, Ont.; Department of Family Medicine (Archibald), University of Ottawa, Ottawa, Ont.; Department of Family Medicine (Phillips), Queen's University, Kingston, Ont.; Department of Family Medicine (Stirrett), Northern Ontario School of Medicine, Sudbury, Ont.; Schulich School of Medicine & Dentistry (Wong), Western University, London, Ont
| | - Eric Wong
- Affiliations: Department of Family Medicine (Grierson, Mercuri, Schabort); Program for Educational Research and Development (Grierson); Division of Emergency Medicine (Mercuri); Division of Pediatric Surgery (Walton), McMaster University, Hamilton, Ont.; College of Family Physicians of Canada (Brailovsky), Mississauga, Ont.; Royal College of Physicians and Surgeons of Canada (Cole), Ottawa, Ont.; Post-MD Program (Abrahams, Bandiera), University of Toronto, Toronto, Ont.; Department of Family Medicine (Archibald), University of Ottawa, Ottawa, Ont.; Department of Family Medicine (Phillips), Queen's University, Kingston, Ont.; Department of Family Medicine (Stirrett), Northern Ontario School of Medicine, Sudbury, Ont.; Schulich School of Medicine & Dentistry (Wong), Western University, London, Ont
| | - Inge Schabort
- Affiliations: Department of Family Medicine (Grierson, Mercuri, Schabort); Program for Educational Research and Development (Grierson); Division of Emergency Medicine (Mercuri); Division of Pediatric Surgery (Walton), McMaster University, Hamilton, Ont.; College of Family Physicians of Canada (Brailovsky), Mississauga, Ont.; Royal College of Physicians and Surgeons of Canada (Cole), Ottawa, Ont.; Post-MD Program (Abrahams, Bandiera), University of Toronto, Toronto, Ont.; Department of Family Medicine (Archibald), University of Ottawa, Ottawa, Ont.; Department of Family Medicine (Phillips), Queen's University, Kingston, Ont.; Department of Family Medicine (Stirrett), Northern Ontario School of Medicine, Sudbury, Ont.; Schulich School of Medicine & Dentistry (Wong), Western University, London, Ont
| |
Collapse
|
18
|
Livingston MH, Mahant S, Ratjen F, Connolly BL, Thorpe K, Mamdani M, Maclusky I, Laberge S, Giglia L, Walton JM, Yang CL, Roberts A, Shawyer AC, Brindle M, Parsons SJ, Stoian CA, Cohen E. Intrapleural Dornase and Tissue Plasminogen Activator in pediatric empyema (DTPA): a study protocol for a randomized controlled trial. Trials 2017. [PMID: 28646887 PMCID: PMC5482972 DOI: 10.1186/s13063-017-2026-0] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/29/2022] Open
Abstract
BACKGROUND A randomized controlled trial of adults with empyema recently demonstrated decreased length of stay in hospital in patients treated with intrapleurally administered dornase alfa and fibrinolytics compared to fibrinolytics alone. Whether this treatment strategy is safe and effective in children remains unknown. METHODS/DESIGN This study protocol is for a superiority, placebo-controlled, parallel-design, multicenter randomized controlled trial. The participants are previously well children admitted to a children's hospital with a diagnosis of empyema requiring chest tube insertion and fibrinolytics administered intrapleurally. Children will be randomized after the treating physician has decided that pleural drainage is required but prior to chest tube insertion. After chest tube insertion, participants in the treatment group will receive intrapleurally administered tissue plasminogen activator (tPA) 4 mg followed by dornase alfa 5 mg. Participants in the placebo group will receive tPA 4 mg followed by normal saline. Study treatments will be administered once daily for 3 days. All participants, parents or caregivers, clinicians, and research personnel will remain blinded. The primary outcome is length of stay from chest tube insertion to discharge from hospital. Secondary outcomes include time to meeting discharge criteria, chest tube duration, fever duration, need for additional procedures, adverse events, hospital readmission, cost of hospitalization, and mortality. DISCUSSION This multicenter randomized controlled trial will assess the safety, effectiveness, and cost-effectiveness of combined treatment with dornase alfa and fibrinolytics compared to fibrinolytics alone for the treatment of empyema in children. TRIAL REGISTRATION ClinicalTrials.gov: NCT01717742 . Registered on 8 October 2012.
Collapse
Affiliation(s)
- Michael H Livingston
- McMaster Children's Hospital, McMaster University, 1280 Main Street West, Hamilton, ON, L8S 4K1, Canada
| | - Sanjay Mahant
- The Hospital for Sick Children, Department of Pediatrics, University of Toronto, 555 University Avenue, Toronto, ON, M5G 1X8, Canada
| | - Felix Ratjen
- The Hospital for Sick Children, Department of Pediatrics, University of Toronto, 555 University Avenue, Toronto, ON, M5G 1X8, Canada
| | - Bairbre L Connolly
- The Hospital for Sick Children, Department of Pediatrics, University of Toronto, 555 University Avenue, Toronto, ON, M5G 1X8, Canada
| | - Kevin Thorpe
- Dalla Lana School of Public Health, University of Toronto, 155 College Street, Toronto, ON, M5T 3M7, Canada.,Applied Health Research Centre of the Li Ka Shing Knowledge Institute, St. Michael's Hospital, University of Toronto, 30 Bond Street, Toronto, ON, M5B 1W8, Canada
| | - Muhammad Mamdani
- Applied Health Research Centre of the Li Ka Shing Knowledge Institute, St. Michael's Hospital, University of Toronto, 30 Bond Street, Toronto, ON, M5B 1W8, Canada
| | - Ian Maclusky
- Children's Hospital of Eastern Ontario, University of Ottawa, 401 Smyth Road, Ottawa, ON, K1H 5B2, Canada
| | - Sophie Laberge
- Centre Hospitalier Universitaire Sainte-Justine, Université de Montréal, 3175 Chemin de la Côte-Sainte-Catherine, Montréal, QC, H3T 1C5, Canada
| | - Lucy Giglia
- McMaster Children's Hospital, McMaster University, 1280 Main Street West, Hamilton, ON, L8S 4K1, Canada
| | - J Mark Walton
- McMaster Children's Hospital, McMaster University, 1280 Main Street West, Hamilton, ON, L8S 4K1, Canada
| | - Connie L Yang
- Department of Pediatrics, Division of Respiratory Medicine, British Columbia's Children's Hospital, University of British Columbia, 4480 Oak Street, Vancouver, BC, V6H 3V4, Canada
| | - Ashley Roberts
- Department of Pediatrics, Division of Respiratory Medicine, British Columbia's Children's Hospital, University of British Columbia, 4480 Oak Street, Vancouver, BC, V6H 3V4, Canada
| | - Anna C Shawyer
- Alberta Children's Hospital, University of Calgary, 2888 Shaganappi Trail NW, Calgary, AB, T3B 6A9, Canada
| | - Mary Brindle
- Alberta Children's Hospital, University of Calgary, 2888 Shaganappi Trail NW, Calgary, AB, T3B 6A9, Canada
| | - Simon J Parsons
- Alberta Children's Hospital, University of Calgary, 2888 Shaganappi Trail NW, Calgary, AB, T3B 6A9, Canada
| | - Cristina A Stoian
- Alberta Children's Hospital, University of Calgary, 2888 Shaganappi Trail NW, Calgary, AB, T3B 6A9, Canada
| | - Eyal Cohen
- The Hospital for Sick Children, Department of Pediatrics, University of Toronto, 555 University Avenue, Toronto, ON, M5G 1X8, Canada.
| |
Collapse
|
19
|
Hamidi S, Livingston MH, Alnaqi A, Yousef Y, Walton JM. Management of a massive choledochal cyst in a 12 year-old girl: Which imaging modalities should be performed preoperatively? Journal of Pediatric Surgery Case Reports 2016. [DOI: 10.1016/j.epsc.2016.04.028] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
|
20
|
Livingston MH, Cohen E, Giglia L, Pirrello D, Mistry N, Mahant S, Weinstein M, Connolly B, Himidan S, Bütter A, Walton JM. Are some children with empyema at risk for treatment failure with fibrinolytics? A multicenter cohort study. J Pediatr Surg 2016; 51:832-7. [PMID: 26964704 DOI: 10.1016/j.jpedsurg.2016.02.032] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/27/2016] [Accepted: 02/07/2016] [Indexed: 11/16/2022]
Abstract
BACKGROUND Guidelines recommend that children with empyema be treated initially with chest tube insertion and intrapleural fibrinolytics. Some patients have poor outcomes with this approach, and it is unclear which factors are associated with treatment failure. METHODS Possible risk factors were identified through a review of the literature. Treatment failure was defined as need for repeat pleural drainage and/or total length of stay greater than 2weeks. RESULTS We retrospectively identified 314 children with empyema treated with fibrinolytics at The Hospital for Sick Children (2000-2013, n=195), Children's Hospital, London Health Sciences Centre (2009-2013, n=39), and McMaster Children's Hospital (2007-2014, n=80). Median length of stay was 11days (range 5-69days). Thirteen percent of children required repeat drainage procedures, and 34% experienced treatment failure. There were no deaths. White blood cell count, erythrocyte sedimentation rate, C-reactive protein, albumin, urea to creatinine ratio, and signs of necrosis on initial chest x-ray were not associated with treatment failure. Multivariable logistic regression demonstrated increased risk with positive blood culture (odds ratio=2.7), immediate admission to intensive care (odds ratio=2.6), and absence of complex septations on baseline ultrasound (odds ratio=2.1). Male gender and platelet count were associated with treatment failure in the univariate analysis but not in the multivariable model. CONCLUSIONS Predicting which children with empyema are at risk for treatment failure with fibrinolytics remains challenging. Risk factors include positive blood culture, immediate admission to intensive care, and absence of complex septations on ultrasound. Routine blood work and inflammatory markers have little prognostic value.
Collapse
Affiliation(s)
- Michael H Livingston
- McMaster Pediatric Surgery Research Collaborative, McMaster University, Hamilton, Ontario, Canada; Clinician Investigator Program, McMaster University, Hamilton, Ontario, Canada
| | - Eyal Cohen
- Division of Pediatric Medicine, Department of Pediatrics, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Lucy Giglia
- Department of Pediatrics, McMaster University, Hamilton, Ontario, Canada
| | - David Pirrello
- McMaster Pediatric Surgery Research Collaborative, McMaster University, Hamilton, Ontario, Canada
| | - Niraj Mistry
- Division of Pediatric Medicine, Department of Pediatrics, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Sanjay Mahant
- Division of Pediatric Medicine, Department of Pediatrics, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Michael Weinstein
- Division of Pediatric Medicine, Department of Pediatrics, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Bairbre Connolly
- Department of Diagnostic Imaging, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Sharifa Himidan
- Division of General & Thoracic Surgery, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Andreana Bütter
- Division of Pediatric Surgery, Western University, London, Ontario, Canada
| | - J Mark Walton
- McMaster Pediatric Surgery Research Collaborative, McMaster University, Hamilton, Ontario, Canada; Division of Pediatric Surgery, McMaster University, Hamilton, Ontario, Canada.
| |
Collapse
|
21
|
Abstract
Oesophageal foreign bodies (FBs) are commonly encountered in an otolaryngology setting. The majority of such cases remain in the paediatric population, where obtaining an accurate history of events is challenging. Oesophageal FBs present in a variety of ways other than dysphagia, which may result in delayed presentation, diagnosis and subsequent treatment. Where an ingested FB is a battery, early removal is advocated owing to the potential for significant complications, a problem highlighted by a patient safety alert issued by NHS England. A common paediatric presentation, torticollis has a multitude of potential underlying causes. We present an unusual case of torticollis in a two-year old girl, subsequently revealed to be caused by an ingested button battery.
Collapse
Affiliation(s)
- J M Walton
- Northampton General Hospital NHS Trust , UK
| | - A Darr
- Walsall Healthcare NHS Trust , UK
| | - A George
- University Hospitals of North Midlands NHS Trust , UK
| |
Collapse
|
22
|
Livingston MH, Zequeira J, Blinder H, Pemberton J, Williams C, Walton JM. Glycerin suppositories used prophylactically in premature infants (SUPP) trial: a study protocol for a pilot randomized controlled trial. Pilot Feasibility Stud 2015; 1:31. [PMID: 27965809 PMCID: PMC5153876 DOI: 10.1186/s40814-015-0024-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2015] [Accepted: 08/12/2015] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND Feeding is a significant challenge for premature infants in the neonatal intensive care unit (NICU). These patients are often treated with glycerin suppositories to stimulate the passage of meconium and prevent feeding intolerance. Unfortunately, the evidence for this practice is inconclusive. METHODS/DESIGN This protocol is for an external pilot study that will assess the feasibility of a superiority, placebo-controlled, parallel-design, multicenter randomized controlled trial. Participants are premature infants treated in a level 3 NICU with a gestational age 24 to 32 weeks and/or birth weight of 500 to 1500 g. Thirty participants will be recruited as part of this external pilot study. Participants will be randomized to glycerin suppository (250 mg) or placebo starting 48 to 72 h after birth and continuing once daily until meconium evacuation is complete or for a maximum of 12 days. The placebo consists of a 250-mg glycerin suppository placed in the diaper rather than the rectum. Study treatments are administered by the charge nurse on duty who is not otherwise involved in patient care. All other clinicians and research personnel will remain blinded. Outcomes for the pilot study are percentage of eligible participants randomized, percentage of infants reaching full enteral feeds, cost, and treatment-related adverse events (rectal bleeding, rectal perforation, and anal fissure). DISCUSSION This external pilot study will assess the feasibility of a multicenter randomized controlled trial of glycerin suppositories in premature infants. The subsequent multicenter trial will have sufficient power to determine whether this treatment strategy is associated with decreased time to full enteral feeds. TRIAL REGISTRATION ClinicalTrials.gov: NCT02153606.
Collapse
Affiliation(s)
- Michael H. Livingston
- McMaster Pediatric Surgery Research Collaborative, McMaster Children’s Hospital, Health Sciences Centre Room 4E3, 1280 Main Street West, Hamilton, Ontario L8S 4K1 Canada
- Clinician Investigator Program, Postgraduate Medical Education, McMaster University, MDCL Rm 3101, 1280 Main Street West, Hamilton, Ontario L8S 4K1 Canada
| | - Jorge Zequeira
- McMaster Pediatric Surgery Research Collaborative, McMaster Children’s Hospital, Health Sciences Centre Room 4E3, 1280 Main Street West, Hamilton, Ontario L8S 4K1 Canada
- Division of Pediatric Surgery, University of Puerto Rico School of Medicine, University of Puerto Rico—Medical Sciences Campus, San Juan, 00921 Puerto Rico
| | - Henrietta Blinder
- McMaster Pediatric Surgery Research Collaborative, McMaster Children’s Hospital, Health Sciences Centre Room 4E3, 1280 Main Street West, Hamilton, Ontario L8S 4K1 Canada
- Division of Pediatric Surgery, Department of Surgery, McMaster University, Health Sciences Centre Room 4E3, 1280 Main Street West, Hamilton, Ontario L8S 4K1 Canada
| | - Julia Pemberton
- McMaster Pediatric Surgery Research Collaborative, McMaster Children’s Hospital, Health Sciences Centre Room 4E3, 1280 Main Street West, Hamilton, Ontario L8S 4K1 Canada
- Division of Pediatric Surgery, Department of Surgery, McMaster University, Health Sciences Centre Room 4E3, 1280 Main Street West, Hamilton, Ontario L8S 4K1 Canada
| | - Connie Williams
- Division of Neonatology, Department of Pediatrics, McMaster University, Health Sciences Centre Room 4F5, 1280 Main Street West, Hamilton, Ontario L8S 4K1 Canada
| | - J Mark Walton
- McMaster Pediatric Surgery Research Collaborative, McMaster Children’s Hospital, Health Sciences Centre Room 4E3, 1280 Main Street West, Hamilton, Ontario L8S 4K1 Canada
- Division of Pediatric Surgery, Department of Surgery, McMaster University, Health Sciences Centre Room 4E3, 1280 Main Street West, Hamilton, Ontario L8S 4K1 Canada
| |
Collapse
|
23
|
Livingston M, Shawyer A, Rosenbaum P, Jones S, Williams C, Walton JM. 76: Glycerin Enemas and Suppositories in Premature Infants: A Systematic Review and Meta-Analysis. Paediatr Child Health 2015. [DOI: 10.1093/pch/20.5.e61] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
|
24
|
Livingston MH, Shawyer AC, Rosenbaum PL, Williams C, Jones SA, Walton JM. Glycerin enemas and suppositories in premature infants: a meta-analysis. Pediatrics 2015; 135:1093-106. [PMID: 25986027 DOI: 10.1542/peds.2015-0143] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/18/2015] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND AND OBJECTIVE Premature infants are often given glycerin enemas or suppositories to facilitate meconium evacuation and transition to enteral feeding. The purpose of this study was to assess the available evidence for this treatment strategy. METHODS We conducted a systematic search of Medline, Embase, Central, and trial registries for randomized controlled trials of premature infants treated with glycerin enemas or suppositories. Data were extracted in duplicate and meta-analyzed using a random effects model. RESULTS We identified 185 premature infants treated prophylactically with glycerin enemas in one trial (n = 81) and suppositories in two other trials (n = 104). All infants were less than 32 weeks gestation and had no congenital malformations. Treatment was associated with earlier initiation of stooling in one trial (2 vs 4 days, P = .02) and a trend towards earlier meconium evacuation in another (6.5 vs 9 days, P = .11). Meta-analysis demonstrated no effect on transition to enteral feeding (0.7 days faster, P = .43) or mortality (P = 0.50). There were no reports of rectal bleeding or perforation but there was a trend towards increased risk of necrotizing enterocolitis with glycerin enemas or suppositories (risk ratio = 2.72, P = .13). These three trials are underpowered and affected by one or more major methodological issues. As a result, the quality of evidence is low to very low. Three other trials are underway. CONCLUSIONS The evidence for the use glycerin enemas or suppositories in premature infants in inconclusive. Meta-analyzed data suggest that treatment may be associated with increased risk of necrotizing enterocolitis. Careful monitoring of ongoing trials is required.
Collapse
Affiliation(s)
- Michael H Livingston
- McMaster Pediatric Surgery Research Collaborative, Clinician Investigator Program
| | - Anna C Shawyer
- Division of Pediatric Surgery, Alberta Children's Hospital, Calgary, Alberta, Canada
| | - Peter L Rosenbaum
- CanChild Center for Childhood Disability Research, Department of Pediatrics, and
| | | | - Sarah A Jones
- Divisions of Pediatric Surgery, Western University, London, Ontario, Canada; and
| | - J Mark Walton
- McMaster Pediatric Surgery Research Collaborative, Division of Pediatric Surgery, McMaster University, Hamilton, Ontario, Canada;
| |
Collapse
|
25
|
Pemberton J, Frankfurter C, Bailey K, Jones L, Walton JM. Gastrostomy matters--the impact of pediatric surgery on caregiver quality of life. J Pediatr Surg 2013; 48:963-70. [PMID: 23701768 DOI: 10.1016/j.jpedsurg.2013.02.012] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/22/2013] [Accepted: 02/03/2013] [Indexed: 10/26/2022]
Abstract
INTRODUCTION While pediatric surgeons consider gastrostomy to be routine treatment for children with feeding difficulties, the impact on the family is not fully understood. This study focuses on Quality of Life (QoL) of parents of children who require a gastrostomy tube. METHODS A prospective repeated measures cohort study was conducted between November 2009 and March 2012. Demographic, surgical, and QoL data were collected at Baseline, 2 weeks, 3, 6, 9, and 12 months after surgery. At each time-point parents completed three QoL measures: Short Form 36v2 (SF-36), Caregiver Strain Index (CSI), and Parent Experience of Childhood Illness (PECI). RESULTS A total of 31 caregivers were recruited with a mean age of 32.6 years (SD=7.0). Overall, a 38% increased risk of depression was seen in the SF-36 when compared to population norms, and a moderate effect was seen in mental health at 12 months (ES=0.56). The CSI demonstrated a decrease in caregiver burden (8.72 to 7.05, p=0.007, 95% CI (0.57-3.18)), while the PECI revealed a decrease in frequency of feelings of guilt, worry, sorrow, anger, and long term uncertainty over 12 months. CONCLUSION Gastrostomy not only improves the child's physical health, but also improves the mental health of the child's caregivers, especially at (or after) one year.
Collapse
Affiliation(s)
- Julia Pemberton
- McMaster Pediatric Surgery Research Collaborative, Hamilton, Ontario, Canada
| | | | | | | | | |
Collapse
|
26
|
Otal D, Wizowski L, Pemberton J, Nagel K, Fitzgerald P, Walton JM. Parent health literacy and satisfaction with plain language education materials in a pediatric surgery outpatient clinic: a pilot study. J Pediatr Surg 2012; 47:964-9. [PMID: 22595582 DOI: 10.1016/j.jpedsurg.2012.01.057] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/20/2012] [Accepted: 01/26/2012] [Indexed: 11/29/2022]
Abstract
BACKGROUND Although significant, the issue of health literacy (HL) among parents attending pediatric surgery outpatient clinics has received little attention. PURPOSE The objectives of this study are to determine the HL skills of parents attending the pediatric surgery outpatient clinic at McMaster Children's Hospital and to describe parent satisfaction with plain language materials. METHODS This cross-sectional study was conducted at the pediatric surgery outpatient clinic at McMaster Children's Hospital. Using convenience sampling for 4 months, parents were recruited and interviewed regarding their demographic status. The Newest Vital Sign tool was used to assess HL. Feedback on the plain language education material was received. RESULTS Seventy-nine individuals were recruited, with a recruitment rate of 62%. Seventy-one percent had adequate HL. English as a first language and Canada as the place of birth were significantly correlated with adequate HL (r = 0.367, P < .001; r = 0.259, P < .05). Parents reported satisfaction with the plain language material, regardless of their HL level. CONCLUSION Twenty-nine percent of parents showed inadequate HL, likely an underestimate owing to study limitations. Parents expressed satisfaction with the plain language material, emphasizing the need for clear, effective communication with patients and families. Future directions include evaluating staff knowledge of a universal precautions approach to health communication and the accessibility of plain language materials.
Collapse
Affiliation(s)
- Damanjot Otal
- McMaster Pediatric Surgery Research Collaborative, Department of Surgery, McMaster University, Hamilton, Ontario, Canada
| | | | | | | | | | | |
Collapse
|
27
|
Choong K, Arora S, Cheng J, Farrokhyar F, Reddy D, Thabane L, Walton JM. Hypotonic versus isotonic maintenance fluids after surgery for children: a randomized controlled trial. Pediatrics 2011; 128:857-66. [PMID: 22007013 DOI: 10.1542/peds.2011-0415] [Citation(s) in RCA: 96] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/12/2023] Open
Abstract
OBJECTIVE The objective of this randomized controlled trial was to evaluate the risk of hyponatremia following administration of a isotonic (0.9% saline) compared to a hypotonic (0.45% saline) parenteral maintenance solution (PMS) for 48 hours to postoperative pediatric patients. METHODS Surgical patients 6 months to 16 years of age with an expected postoperative stay of >24 hours were eligible. Patients with an uncorrected baseline plasma sodium level abnormality, hemodynamic instability, chronic diuretic use, previous enrollment, and those for whom either hypotonic PMS or isotonic PMS was considered contraindicated or necessary, were excluded. A fully blinded randomized controlled trial was performed. The primary outcome was acute hyponatremia. Secondary outcomes included severe hyponatremia, hypernatremia, adverse events attributable to acute plasma sodium level changes, and antidiuretic hormone levels. RESULTS A total of 258 patients were enrolled and assigned randomly to receive hypotonic PMS (N = 130) or isotonic PMS (N = 128). Baseline characteristics were similar for the 2 groups. Hypotonic PMS significantly increased the risk of hyponatremia, compared with isotonic PMS (40.8% vs 22.7%; relative risk: 1.82 [95% confidence interval: 1.21-2.74]; P = .004). Admission to the pediatric critical care unit was not an independent risk factor for the development of hyponatremia. Isotonic PMS did not increase the risk of hypernatremia (relative risk: 1.30 [95% confidence interval: 0.30-5.59]; P = .722). Antidiuretic hormone levels and adverse events were not significantly different between the groups. CONCLUSION Isotonic PMS is significantly safer than hypotonic PMS in protecting against acute postoperative hyponatremia in children.
Collapse
Affiliation(s)
- Karen Choong
- Department of Pediatrics, Faculty of Health Sciences, McMaster University, Hamilton, Ontario, Canada.
| | | | | | | | | | | | | |
Collapse
|
28
|
Grushka JR, Ryckman J, Mueller C, Roessingh ADB, Walton JM, St Vil D, Laberge JM, Bernard C, Nguyen VH, Puligandla PS. Spindle epithelial tumor with thymus-like elements of the thyroid: a multi-institutional case series and review of the literature. J Pediatr Surg 2009; 44:944-8. [PMID: 19433175 DOI: 10.1016/j.jpedsurg.2009.01.030] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/06/2009] [Accepted: 01/15/2009] [Indexed: 11/18/2022]
Abstract
BACKGROUND/PURPOSE Spindle epithelial tumor with thymus-like elements (SETTLE) is a rare tumor of the thyroid observed in children and adolescents. We present a case series of 3 patients with SETTLE, focusing on the clinical and pathologic features of this rare tumor. METHODS Three male patients presented at ages 4.5, 6.5, and 7 years with a right thyroid mass. All were treated by standard hemithyroidectomy. None had evidence of distant metastases at presentation. The diagnosis of SETTLE was confirmed at the time of the initial operation in 2 of the 3 patients. RESULTS All patients had uneventful postoperative courses. Two patients remain disease-free 4 and 7 years postresection, respectively. One patient presented 10 years after resection with shortness of breath and hemoptysis secondary to multiple bilateral parenchymal lung metastases. This patient received chemotherapy against the epithelial components of the tumor with a 25% response based on imaging studies. CONCLUSION Spindle epithelial tumor with thymus-like elements is rare tumor that should be suspected if spindle elements are observed in the resected thyroid specimen. Because these patients may present with delayed metastases, follow-up is recommended. However, chemotherapy against specific tumor elements is only marginally effective.
Collapse
Affiliation(s)
- Jeremy R Grushka
- Division of Pediatric Surgery, The Montreal Children's Hospital, Montreal, Quebec, Canada
| | | | | | | | | | | | | | | | | | | |
Collapse
|
29
|
Jegatheeswaran A, Parmar N, Walton JM, Yip C, Chan AKC. Quantitative analysis of catheter roughness induced by cutting and manipulation: a potential prothrombotic risk. Blood Coagul Fibrinolysis 2007; 18:531-6. [PMID: 17762527 DOI: 10.1097/mbc.0b013e3282010ae6] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
Thrombosis is a major complication of central venous access devices, its incidence depending on material, diameter, tip position, and tip surface. Catheters are usually cut to the appropriate length for accurate positioning. Cutting is not recommended, however, as rough surfaces can serve as a nidus for thrombosis. The present study was performed to assess the roughness of catheter tips provided by various manufacturers versus the roughness once cut and handled. Three types of catheters (Hickman, Port-a-Cath, and Per Q Cath) were cut by scissors, iris scissors, or scalpel, and were handled with debakey forceps, a needle driver, adson with teeth or adson without teeth, to determine the damage created on the catheter. The uncut manufactured tip was compared as a control. Scanning electron microscopy was used for imaging of all samples, and roughness was quantified by atomic force microscopy for the cutting methods. Qualitative results by scanning electron microscopy showed that scalpel-cut and manufactured ends appeared smoother relative to those cut with scissors or iris scissors. This complemented the roughness analysis by atomic force microscopy. Catheters handled by debakey forceps and adsons with teeth showed most roughness, visible as deep holes or a grainy surface when observed by high-magnification scanning electron microscopy. Overall, the smoothest result was produced by scalpel, followed by the manufactured end, scissors, and iris scissors. Handling should be minimized, and use of adsons with teeth, needle drivers and debakey forceps should be avoided, as they can leave permanent damage. Adsons without teeth appeared the least damaging.
Collapse
Affiliation(s)
- Anusha Jegatheeswaran
- Division of Pediatric Surgery, McMaster Children's Hospital, Hamilton, Ontario, Canada
| | | | | | | | | |
Collapse
|
30
|
Abstract
BACKGROUND/PURPOSE The purpose of this study was to compare our initial (1994-1997) and recent (2001-2003) experiences in laparoscopic appendectomy (LA). METHODS A 2-year (2001-2003) retrospective chart review of cases of appendicitis was performed and compared with data obtained from 1994 to 1997 cases. Operating and anesthetic times as well as postoperative outcomes were analyzed. Cases of conversion to open appendectomy were included in the analysis. RESULTS Two hundred and thirty-three LA cases from 2001 to 2003 were compared with 119 cases from 1994 to 1997. Operating time decreased significantly from 58 to 47 minutes in acute appendicitis (AA) and from 80 to 58 minutes in perforated appendicitis (PA). Anesthetic time decreased significantly in both AA (82 to 71 minutes) and PA (106 to 84 minutes). There were significant decreases in the conversion rate in PA (23.4% to 3.5%), although no change was seen in AA. In PA, the incidence of postoperative abscess decreased from 36.2% to 16.5%. There was no significant decrease in length of stay, amount of analgesia used, time to resume regular diet, or incidence of wound infections and bowel obstructions. CONCLUSIONS Ten years of experience in LA has resulted in decreases in anesthetic and operating times for AA and PA as well as decreases in the incidence of abscesses and conversion rates.
Collapse
Affiliation(s)
- Stephanie Phillips
- Division of Pediatric Surgery, McMaster Children's Hospital, Hamilton, Ontario, Canada L8N 3Z5
| | | | | | | | | | | |
Collapse
|
31
|
Affiliation(s)
- David A. Borenstein
- Division of Pediatric Surgery, McMaster Children's Hospital, Hamilton, Ontario, Canada
| | - Brian H. Cameron
- Division of Pediatric Surgery, McMaster Children's Hospital, Hamilton, Ontario, Canada
| | - J. Mark Walton
- Division of Pediatric Surgery, McMaster Children's Hospital, Hamilton, Ontario, Canada
| | - Peter G. Fitzgerald
- Division of Pediatric Surgery, McMaster Children's Hospital, Hamilton, Ontario, Canada
| | - Zakaria Habib
- Division of Pediatric Surgery, McMaster Children's Hospital, Hamilton, Ontario, Canada
| |
Collapse
|
32
|
Gardner VA, Walton JM, Chessell L. A case study utilizing an enteral refeeding technique in a premature infant with short bowel syndrome. Adv Neonatal Care 2003; 3:258-68; quiz 269-71. [PMID: 14695498 DOI: 10.1016/j.adnc.2003.09.002] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Premature and full-term infants may be born with congenital abnormalities or develop acquired lesions of the gastrointestinal tract that require the placement of an enterostomy. Enterostomies can result in significant segments of excluded small bowel, creating a functional short bowel syndrome. Infants with enterostomies can develop dehydration, electrolyte imbalance, and failure to thrive. An illustrative case report of a premature infant with short bowel syndrome treated with enteral refeedings via a mucous fistula is presented. This report highlights the lessons learned from the interdisciplinary team's collective 10-year experience with enteral refeeding in infants with enterostomies. The physiologic basis for this approach is reviewed and literature reports are outlined. The specific nursing care and step-by-step techniques to deliver enteral refeeding through the mucous fistula are provided along with implications for clinical practice, education, and research.
Collapse
Affiliation(s)
- Victoria A Gardner
- Neonatal Intensive Care Unit, McMaster Children's Hospital, Hamilton Health Sciences, Hamilton, ON, Canada.
| | | | | |
Collapse
|
33
|
Abstract
PURPOSE The aim of this study was to describe a new technique for the repair of high and intermediate imperforate anus. METHODS From 1989 to 1999, 22 children with high and intermediate imperforate anus (17 boys, 5 girls) were operated on with a combination of a posterior sagittal and 3-flap perineal anoplasty. Long-term clinical follow up (to a maximum of 10 years) was done in all patients as well as a recent phone interview with a questionnaire regarding bowel function and degree of satisfaction with the result of the surgical correction. A continence ratio (CR, patient score/maximum possible score) was obtained by a blinded interviewer. RESULTS A continence survey was obtained in 19 patients. The average CR was 0.68. The CR for high anomalies was 0.62 and for intermediate anomalies was 0.78 (0.84 for girls and 0.64 for boys). Patients with sacral anomalies had a CR of 0.58. Two patients with Trisomy 21 had associated Hirschsprung's disease and were excluded from analysis. CONCLUSIONS Advantages of this combined surgical approach are excellent anatomic exposure, the ability to limit rectal mobilization to a minimum, reduction of the incidence of mucosal prolapse, the new skin-lined anal canal may assist attainment of continence by providing a "sensory warning zone," and, finally, the cosmetic appearance is satisfactory.
Collapse
Affiliation(s)
- J Bass
- Children's Hospital of Eastern Ontario, Ottawa, Ontario, Canada
| | | | | | | |
Collapse
|
34
|
Hurwitz M, Bahar RJ, Ament ME, Tolia V, Molleston J, Reinstein LJ, Walton JM, Erhart N, Wasserman D, Justinich C, Vargas J. Evaluation of the use of botulinum toxin in children with achalasia. J Pediatr Gastroenterol Nutr 2000; 30:509-14. [PMID: 10817280 DOI: 10.1097/00005176-200005000-00009] [Citation(s) in RCA: 83] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
BACKGROUND Achalasia is rare in children. Recently, injection of botulinum toxin into the lower esophageal sphincter has been studied as an alternative to esophageal pneumatic dilatation or surgical myotomy as treatment for achalasia. In the current study, the effects of botulinum toxin were investigated in the largest known series of children with achalasia. METHODS Treatment for achalasia was assessed in 23 pediatric patients who received botulinum toxin from June 1995 through November 1998. Those who continued to receive botulinum toxin and did not subsequently undergo pneumatic dilatation or surgery were considered repeat responders. Results were compared with those of published studies evaluating the use of botulinum toxin in adults with achalasia. RESULTS Nineteen patients initially responded to botulinum toxin. Mean duration of effect was 4.2 months +/- 4.0 (SD). At the end of the study period, three were repeat responders, three experienced dysphagia but did not receive pneumatic dilatation or surgery, three underwent pneumatic dilatation, eight underwent surgery, three underwent pneumatic dilatation with subsequent surgery, and three awaited surgery. Meta-analysis shows that, in the current study group, the data point expressing time of follow-up evaluation versus percentage of patients needing one injection session without additional procedures (botulinum toxin injection, pneumatic dilatation, or surgery) falls within the curve for those in studies on adult patients receiving botulinum toxin for achalasia. CONCLUSIONS Botulinum toxin effectively initiates the resolution of symptoms associated with achalasia in children. However, one half of patients are expected to need an additional procedure approximately 7 months after one injection session. The authors recommend that botulinum toxin be used only for children with achalasia who are poor candidates for either pneumatic dilatation or surgery.
Collapse
Affiliation(s)
- M Hurwitz
- Department of Pediatrics, University of California Los Angeles School of Medicine, 90095-1752, USA
| | | | | | | | | | | | | | | | | | | | | |
Collapse
|
35
|
Abstract
BACKGROUND/PURPOSE Neonates with enterostomies commonly suffer from a functional short bowel syndrome (SBS) and have a greater risk of electrolyte and fluid loss with poor weight gain. The authors describe their experience with refeeding stoma effluent into the mucous fistula in neonates. METHODS A 5-year (1993 to 1997) chart review of neonates with stoma effluent refeeding was undertaken. Demographics, medical history, surgical procedures, timing, and duration of refeedings were reviewed. Enteral and total parenteral nutritional (TPN) requirements, electrolyte, and acid-base disturbances were recorded. RESULTS Six neonates (gestational ages of 27 to 38 weeks, birth weights of 533 to 3400 g) were identified with nutritional or electrolyte complications before the commencement of refeeding. Enterostomy indications included necrotizing enterocolitis (n = 2), intestinal atresia type 3b (n = 1), complications from ruptured omphalocoele (n = 1), congenital adhesive band obstruction (n = 1), and midgut volvulus after congenital diaphragmatic hernia repair (n = 1). Weight gain during refeeding ranged from 5 to 25 g/kg/d with duration of refeeding lasting 16 to 169 days (two neonates were refed at home) until reanastomoses were done 6 to 44 weeks after the original surgery. There were no complications, and TPN requirements were diminished or eliminated. CONCLUSION This technique represents a simple and safe method, which lessens the need for TPN and electrolyte supplementation in neonates with enterostomies and SBS before reanastomosis.
Collapse
Affiliation(s)
- K Al-Harbi
- Division of Pediatric Surgery, Children's Hospital at Hamilton Health Science Corporation, Ontario, Canada
| | | | | | | | | |
Collapse
|
36
|
Abstract
OBJECTIVE To determine, in a sample of children first prescribed psychostimulants for attention deficit hyperactivity disorder (ADHD) between 1992 and 1994, which child and family factors, components of assessment, and aspects of management, were associated with a favourable treatment response, and with parental satisfaction with management. METHODOLOGY Data were obtained by mail survey in March 1995. Factors considered potentially significant to treatment response and parental satisfaction were entered in a three-step hierarchical multiple regression equation. RESULTS Responses were received from 788 (59.7%) of a possible 1319 parents. Items making a significant individual contribution to both improvement and parental satisfaction were: younger age of the child; amount of information provided by the clinician; shorter interval between review appointments; continued use of medication; and fewer treatment side effects. items contributing only to treatment response were: longer time taken over establishing the diagnosis; and the use of parent and teacher checklists in assessment. CONCLUSIONS These data support early intervention for ADHD. A considered approach to assessment which includes the use of parent and teacher checklists is recommended. Providing adequate information to parents and children is essential. Review intervals of less than 6 months appear to foster better outcomes.
Collapse
Affiliation(s)
- P L Hazell
- University of Newcastle, Callaghan, New South Wales, Australia.
| | | | | | | |
Collapse
|
37
|
Abstract
Esophageal perforation in children is uncommon. A 2 1/2-year-old girl presented with multiple soft tissue injuries of various chronological ages. Initial lateral cervical spine films showed the presence of a prevertebral air collection with soft tissue swelling. Enhanced computerized tomography confirmed the presence of proximal esophageal rupture and a retropharyngeal abscess. External drainage of the abscess and intravenous antibiotics led to resolution of the perforation in 13 days. Discrepancies in the history and the constellation of injuries pointed to an inflicted etiology (through child abuse). Since 1984, 21 case studies have described inflicted esophageal perforation. Common mechanisms of injury include foreign body ingestion and blunt or penetrating external trauma. Early diagnosis of these injuries reduces both acute and long-term morbidity and mortality. Pediatric surgeons must be aware of inflicted injury as an etiology of esophageal and hypopharyngeal perforation.
Collapse
Affiliation(s)
- S Morzaria
- Department of Pediatrics, Children's Hospital at Hamilton Health Sciences Corporation, McMaster University, Ontario, Canada
| | | | | |
Collapse
|
38
|
Abstract
Although mucoepidermoid carcinoma (MEC) is the most common malignant salivary gland neoplasm in childhood and adolescence, it is rarely found in children under the age of 10. A 6-year-old girl had an asymptomatic neck mass for 5 months. Clinical examination findings showed a 1.5-cm smooth and firm but mobile nontender mass located in the upper left anterior cervical triangle, clinically separate from the parotid gland. Ultrasound examination findings showed a vascular mass, with a cystic component, possibly within the tail of the parotid gland. An excisional biopsy was performed and frozen section showed a low-grade MEC. A left superficial parotidectomy was then performed. Final histopathologic examination showed one positive resection margin. Subsequently, reexcision of the surgical site and an upper modified neck dissection was undertaken. This unusual presentation of MEC as a neck mass in one of the youngest reported patients illustrates that the anatomic region for parotid tumors is large. Possibly some of these tumors may arise from heterotopic or accessory parotid tissue.
Collapse
Affiliation(s)
- R G Khadaroo
- Division of Pediatric Surgery, Children's Hospital at Hamilton Health Science Corporation, McMaster University Medical Centre Campus, Ontario, Canada
| | | | | | | | | |
Collapse
|
39
|
Abstract
Throughout lactation, maternal body temperature, nest attendance, activity level and reproductive success of solitary female Djungarian hamsters housed at the recommended ambient temperature of 23 degrees C (Canadian Council on Animal Care guidelines) were compared with those of paired females housed at the same temperature and with solitary females housed at the natural burrow temperature of 18 degrees C. As expected, cooler ambient temperature improved pup survival and weaning weight. Likewise, paternal presence largely compensated for the poor pup growth typical at 23 degrees C. However, the mechanisms were not the same. Females at reduced ambient temperatures were as hyperthermic as females at the higher temperature and spent the same proportion of their day at very high body temperatures. However, the steeper temperature gradient available for passive cooling allowed those females to enhance maternal care by shortening their nest bout absences. In contrast, body temperatures of paired females were tightly regulated compared to the hyperthermia of solitary females and rarely included the highest body temperatures. This alleviation of maternal hyperthermia was not achieved through a reduction in nest attendance. Therefore, maternal hyperthermia in Djungarian hamsters is not essential and may be considered a substantial cost to females when males are not present.
Collapse
Affiliation(s)
- J M Walton
- Department of Biology, Queen's University, Kingston, Canada
| | | |
Collapse
|
40
|
Carr VJ, Lewin TJ, Reid AL, Walton JM, Faehrmann C. An evaluation of the effectiveness of a consultation-liaison psychiatry service in general practice. Aust N Z J Psychiatry 1997; 31:714-25; discussion 726-7. [PMID: 9400878 DOI: 10.3109/00048679709062685] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
OBJECTIVE This study evaluated the 6-month outcome of patients referred by their general practitioner (GP) to a consultation-liaison (C-L) psychiatry service provided to eight group general practices. METHOD Over a 12-month period, there were 307 referrals to the C-L psychiatry service of whom 86 consented to take part in an outcome study. Two different control groups were examined comprising patients seen by the same GPs but not referred to the C-L service, who were matched with the C-L referrals on the basis of either demographic characteristics (n = 86) or initial symptomatology (n = 59). Clinical interviews were conducted at recruitment to the outcome study using the Composite International Diagnostic Interview (CIDI), while postal questionnaires were used at both the initial and 6-month assessments. RESULTS Data reported include DSM-III-R clinical audit and CIDI diagnoses, changes in current symptomatology (SCL-90-R) and changes in global ratings of physical health, emotional health, social relationships and ability to perform everyday duties. Consultation-liaison referrals without symptom-matched controls (n = 27), being patients with higher levels of symptoms initially, were more likely to be referred to other psychiatric services for treatment. They also showed more marked improvement over time on the selected outcome measures. However, there were no significant differences in the patterns of change over time between symptom-matched C-L referrals and their non-referred controls. CONCLUSIONS The findings from the 6-month outcome study raise doubts about the overall benefit of the current C-L service relative to usual GP care. Improving the quality of psychiatric care in general practice is likely to require a range of interrelated strategies, including C-L psychiatry services, GP education and well-functioning links with public mental health services.
Collapse
Affiliation(s)
- V J Carr
- Discipline of Psychiatry, Faculty of Medicine and Health Sciences, University of Newcastle, Callaghan, New South Wales, Australia.
| | | | | | | | | |
Collapse
|
41
|
Abstract
Esophageal achalasia (EA) has been historically treated by esophageal dilatation or myotomy with or without fundoplication. Botulinum toxin (Botox-Allergan) use in pediatric EA has not been previously described. The authors' objective was to observe the efficacy of botulinum toxin injection into the lower esophageal sphincter (LES) for EA. An 11-year-old boy presented with a 9-month history of frequent pneumonia, productive cough, and a 1-year history of chest discomfort and odynophagia. Chest radiograph showed changes compatible with aspiration. Upper gastrointestinal (UGI) series showed typical narrowing of the LES, and 24-hour pH study showed no reflux. Esophageal manometry showed classic findings of achalasia. An upper gastrointestinal endoscopy was performed showing a huge volume of retained food. A direct four-quadrant injection was performed with a total of 100 U of botulinum toxin into the LES. UGI series showed improvement in esophageal emptying. Esophageal manometry showed impressive improvement in LES pressure (preinjection, 44.1 mm Hg to postinjection mean of 16.6 mm Hg), percent relaxation (preinjection, 30% to postinjection, 58.8%), and duration of relaxation (preinjection, 1.9 seconds to postinjection, 11 seconds). The patient has not had any further respiratory symptoms, chest pain, or odynophagia in 8 months of follow-up. Botulinum toxin injection is simple and effective for EA and merits its study in a prospective manner in the pediatric population.
Collapse
Affiliation(s)
- J M Walton
- Division of Surgery at the Children's Hospital, Chedoke-McMaster Hospitals, Hamilton, Ontario, Canada
| | | |
Collapse
|
42
|
Carr VJ, Faehrmann C, Lewin TJ, Walton JM, Reid AA. Determining the effect that consultation-liaison psychiatry in primary care has on family physicians' psychiatric knowledge and practice. Psychosomatics 1997; 38:217-29. [PMID: 9136250 DOI: 10.1016/s0033-3182(97)71458-0] [Citation(s) in RCA: 19] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
The impact of a community-based consultation-liaison (C-L) psychiatry service on family physicians' levels of psychiatric knowledge, diagnostic and treatment confidence, and patterns of referral to mental health care agencies was evaluated over a 12-month period. The physicians with long-term access to the C-L service had higher levels of psychiatric knowledge than those with short-term or no access. However, there was no evidence that the C-L service produced changes in the physicians' levels of clinical confidence, referral likelihood, or psychiatric knowledge during the evaluation period. Significant predictors of psychiatric knowledge were age (younger) and gender (women). The participating physicians were highly satisfied with the service and preferred it over other possible referral agencies. However, community C-L services in family practice appear to have a limited role in the provision of psychiatric care and are not an efficient way for improving family physicians' levels of psychiatric knowledge or altering their practices. The appropriate role of community C-L psychiatry may be as one component of a comprehensive service-delivery strategy integrated within ongoing, formal family-physician educational programs.
Collapse
Affiliation(s)
- V J Carr
- Faculty of Medicine and Health Sciences, University of Newcastle, Australia
| | | | | | | | | |
Collapse
|
43
|
Abstract
OBJECTIVES To define a method for measurement of the cross sectional area and volume of the quadriceps femoris muscle using magnetic resonance imaging (MRI) in conjunction with stereology, and to compare the results of measurements obtained by the MRI method with those obtained by the conventional method of static B-mode ultrasound in order to evaluate whether MRI is a reliable alternative to ultrasound. METHODS A preliminary MRI study was undertaken on a single female volunteer in order to optimise the scanning technique and sampling design for estimating the muscle volume using the Cavalieri method. Ten healthy volunteers participated in the method comparison study. Each volunteer underwent static B-mode ultrasonography, immediately followed by MRI. The cross sectional area of the quadriceps femoris was estimated at the junction of the proximal one third and distal two thirds of the thigh, and seven systematic sections of the thigh were obtained in order to estimate muscle volume by both modalities. RESULTS Seven sections through the muscle are required to achieve a coefficient of error of 4-5%. There was no significant difference in the cross sectional area estimates or volume estimates when ultrasound and MRI were compared. CONCLUSION Muscle cross sectional area and volume can be measured without bias by MRI in conjunction with stereological methods and the method is a reliable alternative to static B-mode ultrasound for this purpose.
Collapse
Affiliation(s)
- J M Walton
- Department of Medical Imaging, University of Liverpool, United Kingdom
| | | | | |
Collapse
|
44
|
Moscrip V, Walton JM. Ultrasonographic assessment of adipose tissue volume. Br J Sports Med 1997; 31:84-5. [PMID: 9132227 PMCID: PMC1332491 DOI: 10.1136/bjsm.31.1.84] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
|
45
|
Abstract
OBJECTIVE This paper describes the characteristics of 303 consecutive referrals, over a 12-month period, to a consultation-liaison (C-L) psychiatry service provided to eight group general practices in Newcastle, Australia. METHOD A purpose designed service audit form was used throughout the evaluation period to collect information about demographic characteristics, reasons for referral, service contacts, psychiatric diagnoses and clinical management. In addition, patients were invited to participate in a separate, prospective outcome evaluation study, which involved structured interviews and questionnaires. RESULTS The most common reasons for referral were: depression (33%); anxiety (12%); diagnostic assessment (9%); and impaired relationships (8%). The most common psychiatric diagnoses were: mood disorders (29%); mild, transient conditions (29%); anxiety (14%); and substance abuse disorders (12%). Following the psychiatric consultation(s), GPs were actively involved in patients' treatment in 53% of cases. However, there was a higher than expected rate of referral (44%) to another mental health agency. Selected comparisons are also reported between patients referred to the C-L service (n = 303) and a sample of non-referred GP attenders (n = 535). CONCLUSIONS As expected, the diagnostic profiles of patients attending the C-L service differed in several respects from those using similar services in general hospitals. There were comparatively low rates of organic brain syndromes, suicide risk evaluations, and problems of differential diagnosis of somatic symptoms. Greater emphasis needs to be placed on more formal psychiatric education for GPs, on ways of screening out from the referral process those patients with mild, transient conditions who do not require specialist expertise, and on the development of strategies to help GPs manage such conditions.
Collapse
Affiliation(s)
- V J Carr
- Disciplines of Psychiatry and General Practice, Faculty of Medicine and Health Sciences, University of Newcastle, Callaghan, Australia
| | | | | | | | | |
Collapse
|
46
|
Walton JM, Irwin KS, Whitehouse GH. Comparison of real-time ultrasonography and magnetic resonance imaging in the assessment of urinary bladder volume. Br J Urol 1996; 78:856-61. [PMID: 9014708 DOI: 10.1046/j.1464-410x.1996.02398.x] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
OBJECTIVE To compare estimates of bladder volume obtained by conventional real-time ultrasonography with those obtained from magnetic resonance imaging (MRI) by the Cavalieri method of unbiased stereology. SUBJECTS AND METHODS The study comprised nine subjects (four men and five women, mean age 23 years, range 18-34) with no history of bladder disease. Before micturition, each volunteer underwent ultrasonography, immediately followed by MRI. The volunteers then voided the true voided volume of urine was measured and the imaging protocols were repeated in the same order after micturition. The bladder volume was estimated from ultrasonography using the formula: volume = 0.7 (L x TS x AP), (where L is the maximum supero-inferior diameter. AP the maximum anteroposterior diameter and TS the maximum transverse diameter) and from MRI using the Cavalieri method. For each imaging modality, the volume of urine voided was estimated as the difference in the volume estimate before and after micturition. RESULTS The mean percentage coefficient of variation for the estimates of bladder volume by ultrasonography was 2.17 before and 4.43 after micturition. There was no significant difference in the replicate estimates of each bladder diameter by ultrasonography before and after micturition (P = 0.98). The MRI method consistently underestimated the voided volume: the mean discrepancy between the estimated voided volume and the true voided volume was 7.7 ml, and -67.7 ml for the ultrasonographic and MRI estimates, respectively, which are significantly different (P = 0.02) when assessed using a multifactor ANOVA. Further analysis using multiple-range tests showed a significant difference between the voided volume estimated by MRI and the corresponding true voided volume. There was no difference between the voided volume estimated by ultrasonography and the corresponding true volume. CONCLUSION Ultrasonographic estimates of voided volume were more reliable than the those obtained using the MRI method. This is possibly due to a delay between micturition and the acquisition of MR images after micturition, which allowed the bladder to partly refill with urine. The empirical approach using measurements from ultrasonograms provides a fast and reliable technique: ultrasonography remains the recommended imaging modality for estimating bladder volume.
Collapse
Affiliation(s)
- J M Walton
- Department of Medical Imaging, University of Liverpool, UK
| | | | | |
Collapse
|
47
|
Hazell PL, McDowell MJ, Walton JM. Management of children prescribed psychostimulant medication for attention deficit hyperactivity disorder in the Hunter region of NSW. Med J Aust 1996; 165:477-80. [PMID: 8937367 DOI: 10.5694/j.1326-5377.1996.tb138611.x] [Citation(s) in RCA: 33] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
OBJECTIVE To examine local procedures for assessment of attention deficit hyperactivity disorder (ADHD) and its management with psychostimulant medication and to compare these with published practice guidelines. DESIGN Retrospective postal survey. PARTICIPANTS Parents of children living in the Hunter region of New South Wales first prescribed psychostimulants between 1992 and 1994. MAIN OUTCOME MEASURES Procedures for diagnostic assessment, treatment monitoring and continuing management. RESULTS 788 parents (60%) responded. Diagnostic assessment procedures complied with published guidelines for about 70%, and detection of comorbid conditions was consistent with community prevalence estimates. There was systematic assessment of treatment response with questionnaires in only a third. Some children with academic or behavioural problems (19%-24% and 32%, respectively), almost 50% with emotional problems and 63% with motor problems were not receiving treatment for these difficulties. Modal interval for review was six months. Trials off medication were most commonly during school holidays, contrary to recommendations of the New South Wales Health Department. Most parents reported considerable improvement in their children's quality of life with medication. CONCLUSIONS Problems comorbid with ADHD are detected often. Areas of deficiency in management of ADHD include the low rate of contact with schools for diagnostic assessment and determining treatment efficacy, poor support for comorbid problems, infrequent review, and inadequate methods for determining need to continue treatment.
Collapse
Affiliation(s)
- P L Hazell
- Faculty of Medicine and Health Science, University of Newcastle, NSW.
| | | | | |
Collapse
|
48
|
Abstract
External splinting of the trachea has been used alone or in combination with aortopexy for the treatment of severe tracheomalacia. The authors describe the case of a 12-year-old boy who had a Marlex mesh splint placed because of life-threatening primary tracheomalacia at 6 months of age. He presented at 12 years of age with a 5-month history of shortness of breath on exertion, dry cough, and audible wheeze. Radiological and endoscopic examinations showed near-complete obstruction of the orifice of the right mainstem bronchus by a large polypoid granuloma. Initially the patient was treated with endoscopic resection on two occasions, but the granuloma and bronchial obstruction recurred each time. He underwent a right thoracotomy, which showed that the lower edge of the mesh had eroded through the trachea wall and was acting as a nidus for granuloma formation. After removal of the mesh, the resulting defect at the site of erosion of the trachea was closed with a pericardial patch. The postoperative course was uncomplicated, and the patient remains well 2 years after surgery. External splinting of the trachea has been shown to be effective in the treatment of complicated tracheomalacia, but one must be aware of the potential long-term complications, as demonstrated in this case.
Collapse
Affiliation(s)
- P G Fitzgerald
- Children's Hospital at Chedoke McMaster, Hamilton, Ontario
| | | |
Collapse
|
49
|
Fitzgerald PG, Langer JC, Cameron BH, Park AE, Marcaccio MJ, Walton JM, Skinner MA. Pediatric laparoscopic splenectomy using the lateral approach. Surg Endosc 1996; 10:859-61. [PMID: 8694957 DOI: 10.1007/bf00189553] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
Laparoscopic splenectomy in children has been shown to be safe, to reduce postoperative pain and hospital stay, and to accelerate return to full activities. We describe our experience with a four-port "lateral" approach in 18 patients. Patients were placed in the lateral decubitus position and the table was flexed to separate the left subcostal margin and iliac crest. The camera port was inserted at the umbilicus and additional ports were placed in the epigastrium and left lower quadrant. After mobilization of the splenic flexure a port was inserted in the left flank below the 12th rib for elevation of the spleen. A 30 degrees laparoscope was used and the splenic vessels were controlled with an endo-GIA and/or clips. The spleens were placed in a bag, morcellated, and extracted through a port site. Eight females and 10 males with a median age of 12.5 years (5-17 years) and weight of 55.5 kg (17-124 kg) underwent splenectomy of idiopathic thrombocytopenia purpora (10), spherocytosis (6), elliptocytosis (1), and Hodgkin's disease (1). The median operating time was 160 min (90-300 min) and median blood loss was 105 ml (5-350 ml). Accessory spleens were removed in four cases. Three patients required extensions of a port site to remove large spleens which could not be placed in a bag. The sole complication was a transient pancreatitis with associated pleural effusion. The median postoperative hospital stay was 2 days (1-11 days) and time to full activities was 8 days (3-25 days). The lateral approach affords excellent visualization of the splenic vessels, pancreas, and accessory spleens. This approach is safe and reliable and is our preferred approach for laparoscopic splenectomy in children.
Collapse
Affiliation(s)
- P G Fitzgerald
- Children's Hospital, Chedoke-McMaster, 1200 Main St. W., Hamilton, ON L8N 325, Canada
| | | | | | | | | | | | | |
Collapse
|
50
|
Abstract
This paper describes the construction, refinement and implementation of a self-administered measure of personal hopefulness, the Hunter Opinions and Personal Expectations Scale (HOPES). Initial state and trait versions of the HOPES instrument were utilized in three separate studies, comprising a medical student sample (N = 211), an adolescent male sample (N = 280) and a psychiatric hospital staff sample (N = 318). A revised 20-item, two factor, trait version of the scale was then utilized in a prospective, longitudinal investigation (N = 753) of the psychosocial sequelae of the earthquake which struck Newcastle (Australia) in December, 1989. Data from all four studies provide strong support for the HOPES instrument's construct, concurrent and predictive validity. Global personal hopefulness (GPH) was shown to be an enduring characteristic of individuals, with a test-retest correlation of r = + 0.71 (over 64 weeks). The association between GPH and trait anxiety (r = -0.64) raised the possibility of redefining anxiety as hope under threat. The hope subscale (HS) and the despair subscale (DS) were moderately negatively correlated (r = -0.32), suggesting that hope and despair are not simply polar opposites. There were no gender differences in GPH scores, however, there were relatively clear age effects, with those aged 70 years and over reporting the lowest levels of personal hopefulness. GPH was negatively correlated with post-earthquake scores on the General Health Questionnaire (r = -0.33), the Impact of Event Scale (r = -0.33), the Beck Depression Inventory (r = -0.54) and the global symptom index from the SCL-90-R (r = -0.43). Overall, the contribution made by personal hopefulness to post-earthquake morbidity was equal to the contributions made by initial exposure to disruption and threat experiences.
Collapse
Affiliation(s)
- K P Nunn
- Department of Psychiatry, Royal Alexandra Hospital for Children, Westmead, NSW, Australia
| | | | | | | |
Collapse
|