Prospective monitoring of adverse events following vaccination with Modified vaccinia Ankara - Bavarian Nordic (MVA-BN) administered to a Canadian population at risk of Mpox: A Canadian Immunization Research Network study

MVA-BN is an orthopoxvirus vaccine that provides protection against both smallpox and mpox. In June 2022, Canada launched a publicly-funded vaccination campaign to offer MVA-BN to at-risk populations including men who have sex with men (MSM) and sex workers. The safety of MVA-BN has not been assessed in this context. To address this, the Canadian National Vaccine Safety Network (CANVAS) conducted prospective safety surveillance during public health vaccination campaigns in Toronto, Ontario and in Vancouver, British Columbia. Vaccinated participants received a survey 7 and 30 days after each MVA-BN dose to elicit adverse health events. Unvaccinated individuals from a concurrent vaccine safety project evaluating COVID-19 vaccine safety were used as controls. Vaccinated and unvaccinated participants that reported a medically attended visit on their 7-day survey were interviewed. Vaccinated participants and unvaccinated controls were matched 1:1 based on age group, gender, sex and provincial study site. Overall, 1,173 vaccinated participants completed a 7-day survey, of whom 75 % (n = 878) also completed a 30-day survey. Mild to moderate injection site pain was reported by 60 % of vaccinated participants. Among vaccinated participants 8.4 % were HIV positive and when compared to HIV negative vaccinated individuals, local injection sites were less frequent in those with HIV (48 % vs 61 %, p = 0.021), but health events preventing work/school or requiring medical assessment were more frequent (7.1 % vs 3.1 %, p = 0.040). Health events interfering with work/school, or requiring medical assessment were less common in the vaccinated group than controls (3.3 % vs. 7.1 %, p < 0.010). No participants were hospitalized within 7 or 30 days of vaccination. No cases of severe neurological disease, skin disease, or myocarditis were identified. Our results demonstrate that the MVA-BN vaccine appears safe when used for mpox prevention, with a low frequency of severe adverse events and no hospitalizations observed.

Implementing evidence-based practice: A context analysis to examine use of task-based approaches to upper-limb rehabilitation

Statement of context

Many occupational therapists experience challenges in implementing evidence-based practice, which may be best approached as a context-specific enterprise.

Critical reflection on practice

This practice analysis article reports the results of analyzing 24 home programs that occupational therapists issued to rehabilitation inpatients with stroke upon their discharge home. Home programs did not reflect a task-based approach to upper-limb recovery, even though this is supported by established evidence. Examination of contextual factors provides a framework to facilitate evidence implementation.

Implications for practice

Occupational therapists may optimize evidence-based practice implementation by first evaluating and addressing practice-specific contextual factors.

Implementation Intentions for Self-Selected Occupational Therapy Goals: Two Case Reports

OBJECTIVE

We evaluated the feasibility of an intervention combining metacognitive strategy instruction (MSI) with training in implementation intentions for adults with mild traumatic brain injury (mTBI). Implementation intentions are written premade decision statements specifying when, where, and how goal behaviors are to be enacted.

METHOD

Two participants with mTBI received a six-session intervention that included setting a daily implementation intention for an occupational therapy goal. A scoring rubric was used to evaluate the quality of implementation intentions; goal achievement was measured using the Canadian Occupational Performance Measure (COPM) and goal attainment scaling.

RESULTS

All implementation intentions received perfect quality scores, suggesting participants learned to correctly craft implementation intentions. Improvements in COPM self-ratings exceeded minimal detectable change values; goal attainment levels indicated better-than-expected goal achievement.

CONCLUSION

An intervention combining MSI and implementation intention training appears to be feasible. As an adjunct to MSI, implementation intentions may contribute to clients' ability to achieve their own occupational performance goals. Further study is needed.

Focus Forward: Outcomes of a Brief Occupational Therapy Intervention for Cancer-Related Cognitive Dysfunction

Date Presented 3/30/2017

Results of this pilot and feasibility study indicate that women with breast cancer who received a brief occupational therapy intervention for cancer-related cognitive dysfunction experienced pre–post improvements in self-reported cognition and occupational functioning.

Primary Author and Speaker: Shayne Hopkins

Contributing Authors: Mary Vining Radomski, Marsha Finkelstein, Mattie Anheluk, Kristin Berling, Michele Darger, Kim Grabe, M. Tracy Morrison, Joette Zola, Nancy Hutchison

Further Development of the Assessment of Military Multitasking Performance: Iterative Reliability Testing

The Assessment of Military Multitasking Performance (AMMP) is a battery of functional dual-tasks and multitasks based on military activities that target known sensorimotor, cognitive, and exertional vulnerabilities after concussion/mild traumatic brain injury (mTBI). The AMMP was developed to help address known limitations in post concussive return to duty assessment and decision making. Once validated, the AMMP is intended for use in combination with other metrics to inform duty-readiness decisions in Active Duty Service Members following concussion. This study used an iterative process of repeated interrater reliability testing and feasibility feedback to drive modifications to the 9 tasks of the original AMMP which resulted in a final version of 6 tasks with metrics that demonstrated clinically acceptable ICCs of > 0.92 (range of 0.92–1.0) for the 3 dual tasks and > 0.87 (range 0.87–1.0) for the metrics of the 3 multitasks. Three metrics involved in recording subject errors across 2 tasks did not achieve ICCs above 0.85 set apriori for multitasks (0.64) and above 0.90 set for dual-tasks (0.77 and 0.86) and were not used for further analysis. This iterative process involved 3 phases of testing with between 13 and 26 subjects, ages 18–42 years, tested in each phase from a combined cohort of healthy controls and Service Members with mTBI. Study findings support continued validation of this assessment tool to provide rehabilitation clinicians further return to duty assessment methods robust to ceiling effects with strong face validity to injured Warriors and their leaders.

Composition of a vision screen for servicemembers with traumatic brain injury: consensus using a modified nominal group technique

Vision impairment is common in the first year after traumatic brain injury (TBI), including among service members whose brain injuries occurred during deployment in Iraq and Afghanistan. Occupational therapy practitioners provide routine vision screening to inform treatment planning and referral to vision specialists, but existing methods are lacking because many tests were developed for children and do not screen for vision dysfunction typical of TBI. An expert panel was charged with specifying the composition of a vision screening protocol for servicemembers with TBI. A modified nominal group technique fostered discussion and objective determinations of consensus. After considering 29 vision tests, the panel recommended a nine-test vision screening that examines functional performance, self-reported problems, far-near acuity, reading, accommodation, convergence, eye alignment and binocular vision, saccades, pursuits, and visual fields. Research is needed to develop reliable, valid, and clinically feasible vision screening protocols to identify TBI-related vision disorders in adults.

Development and preliminary reliability of a multitasking assessment for executive functioning after concussion

OBJECTIVES. Executive functioning deficits may result from concussion. The Charge of Quarters (CQ) Duty Task is a multitask assessment designed to assess executive functioning in servicemembers after concussion. In this article, we discuss the rationale and process used in the development of the CQ Duty Task and present pilot data from the preliminary evaluation of interrater reliability (IRR). METHOD. Three evaluators observed as 12 healthy participants performed the CQ Duty Task and measured performance using various metrics. Intraclass correlation coefficient (ICC) quantified IRR. RESULTS. The ICC for task completion was .94. ICCs for other assessment metrics were variable. CONCLUSION. Preliminary IRR data for the CQ Duty Task are encouraging, but further investigation is needed to improve IRR in some domains. Lessons learned in the development of the CQ Duty Task could benefit future test development efforts with populations other than the military.

Development of a measure to inform return-to-duty decision making after mild traumatic brain injury

Mild traumatic brain injury (mTBI), a principal injury of the wars in Iraq and Afghanistan, can result in significant morbidity. To make accurate return-to-duty decisions for soldiers with mTBI, military medical personnel require sensitive, objective, and duty-relevant data to characterize subtle cognitive and sensorimotor injury sequelae. A military-civilian research team reviewed existing literature and obtained input from stakeholders, end users, and experts to specify the concept and develop a preliminary assessment protocol to address this need. Results of the literature review suggested the potential utility of a test based on dual-task and multitask assessment methods. Thirty-three individuals representing a variety of military and civilian stakeholders/experts participated in interviews. Interview data suggested that reliability/validity, clinical feasibility, usability across treatment facilities, military face validity, and capacity to challenge mission-critical mTBI vulnerabilities were important to ultimate adoption. The research team developed the Assessment of Military Multitasking Performance, a tool composed of eight dual and multitasking test-tasks. A concept test session with 10 subjects indicated preliminary face validity and informed modifications to scoring and design. Further validation is needed. The Assessment of Military Multitasking Performance may fill a gap identified by stakeholders for complex cognitive/motor testing to assist return-to-duty decisions for service members with mTBI.

Comparison of observer reliability of three-dimensional cephalometric landmark identification on subject images from Galileos and i-CAT cone beam CT

OBJECTIVES

Recently, there has been increasing interest in the use of cone beam CT (CBCT) for three-dimensional cephalometric analysis and craniofacial reconstruction in orthodontic and orthognathic surgical treatment planning. However, there is a need to redefine the cephalometric landmarks in three dimensional cephalometric analysis and to demonstrate the reproducibility of landmark identification on the type of CBCT machine being used.

METHODS

CBCT images of 20 subjects aged 15-25 years were selected, ten each from Galileos(®) (Sirona Dental Systems Inc., Bensheim, Germany) and Next Generation i-CAT(®) (Imaging Sciences International, Hatfield, PA). 2 observers located 18 landmarks on each subject twice using Dolphin-3D v. 11 software (Dolphin Imaging and Management Systems, Chatsworth, CA). Inter- and intraobserver reliability was assessed using Euclidean distances and linear mixed models.

RESULTS

Overall, the intra- and interobserver reliability was excellent for both machines. The landmarks Gonion, Nasion, Orbitale and Anterior Nasal Spine (ANS) showed the greatest median Euclidean distances for both intra- and interobserver measurements. There were significant observer effects in the unified models for Sella, Menton and all six dental landmarks. For Sella, the distances between the measures were significantly smaller (more closely spaced) on the i-CAT machine than on the Galileos in both intra- and interobserver measurements.

CONCLUSIONS

The intra- and interobserver reliability was excellent for both machines. Some of the landmarks were not as reproducible as others. Which machine produced the highest reliability depended on the landmark considered.

The complex association of race and leaving the pediatric emergency department without being seen by a physician

OBJECTIVES

This study examined the influence of race and language on leaving the emergency department (ED) without complete evaluation and treatment (LWCET).

METHODS

This retrospective, case-cohort study examined LWCET among patients discharged home from 2 EDs between March 2, 2009, and March 31, 2010. Race and language were obtained by family self-report. We also explored wait time to see a physician as an explanation of racial disparities.

RESULTS

One thousand two hundred eighty-five (1.7%) of 76,931 ED encounters ended in LWCET. Factors increasing LWCET were high ED activity, low acuity, and medical assistance (MA) insurance. American Indian, biracial, African American, and Hispanic races were also associated with higher odds of LWCET among visits by MA insurance patients compared with those of white patients on private insurance. Restricting the analysis to visits by MA insurance patients, only American Indian race was associated with LWCET compared with white race. Visits by patients using an interpreter or speaking a language other than English at home had lower odds of ending in LWCET. Sensitivity analyses in subgroups confirmed these findings. We developed a measure of ED activity that correlated well with wait time to see a physician (correlation coefficient = 0.993; P < 0.001). Among non-LWCET visits, wait time to see a practitioner did not correlate with racial disparities in LWCET.

CONCLUSIONS

Race, language, and insurance status interact to form a complex relationship with LWCET. Medical assistance insurance status appears to account for much of the excessive instances of LWCET seen in nonwhites. After restricting the analysis to MA insurance patients, only visits by American Indian patients had higher odds of LWCET compared with whites on MA insurance. Wait time to see a physician did not explain racial differences in LWCET.

Validated Assessment Tools for Pediatric Airway Endoscopy Simulation

Objective

To determine the interrater reliability and construct validity of 3 separate assessment tools for assessing trainee skills in pediatric airway endoscopy simulation.

Design

An Objective Structured Assessment of Technical Skills (OSATS) was developed in which examinees were asked to name and assemble the airway foreign body instruments and retrieve a foreign body from an infant airway mannequin. Each examinee’s performance was assessed in a blinded fashion by 3 pediatric otolaryngology faculty at separate residency programs using 3 assessment tools: (1) objective quantifiable measures list (eg, assists needed, forceps openings, foreign body drops), (2) 15-point OSATS checklist, and (3) Global Rating Index for Technical Skills (GRITS).

Setting

Otolaryngology residency program.

Subjects

Examinees (medical students, n = 3; otolaryngology residents, n = 17; pediatric otolaryngology faculty, n = 3) and raters (n = 3).

Main Outcome Measures

Interrater reliability and construct validity.

Results

Anonymized split-screen videos simultaneously capturing each examinee’s instrument handling and the endoscopic videos were created for all 23 examinees. Nineteen videos were chosen for review by 3 raters. The interrater reliability as measured by the intraclass correlation for objective quantifiable measures ranged from 0.46 to 0.98. The intraclass correlation coefficient was 0.95 for the 15-point OSATS checklist and 0.95 for the GRITS; both showed a high degree of construct validity with scores correlating with previous experience.

Conclusion

Assessment tools for skills assessments must have high interrater reliability and construct validity. When assessing trainee skills in pediatric airway foreign body scenarios, the 15-point OSATS checklist developed by this group or the GRITS meets these criteria.

Predicting Surgical Outcomes in Pediatric Cervicofacial Nontuberculous Mycobacterial Lymphadenitis

Objectives:

We examined surgical outcomes in children with cervicofacial nontuberculous mycobacterial lymphadenitis and attempted to identify predictors of complications.

Methods:

A retrospective chart review from 2 tertiary pediatric centers was used to identify 11 presentation or operative variables (age at surgery, gender, symptom duration, pain, violaceous skin changes, skin breakdown, fluctuance, purified protein derivative positivity, operative procedure, use of nerve integrity monitoring, and use of skin flap advancement) and to compare these to 5 postoperative complications (facial nerve dysfunction [paresis or paralysis], poor scarring, recurrence, wound infection, and wound dehiscence without infection).

Results:

The 45 patients analyzed for presentation or operative variables (28 female, 17 male; average age, 31.2 months) typically presented with painless masses averaging 8.2 weeks in duration, along with violaceous skin changes in 29 of the 45 cases (64%) and skin breakdown in 9 cases (20%). The surgical procedures included parotidectomy with or without selective lymphadenectomy in 38 of the 45 cases (84%) and lymphadenectomy alone in 7 cases (16%). Skin resection and cervicofacial advancement flap reconstruction was performed in 20 cases (44%). Nerve integrity monitoring was utilized in 32 cases (71%). In the 44 patients analyzed for postoperative complications, we found facial nerve paresis in 14 (31.8%), poor scarring in 9 (20.5%), wound infection in 6 (13.6%), recurrence in 4 (9.1%), and facial nerve paralysis in 2 (4.5%). Nine of the 14 cases (64.3%) of initial facial nerve paresis resolved. At final follow-up, facial nerve paresis persisted in 5 of the 14 children (35.7%) with initial postoperative paresis and in 1 of the 2 children (50.0%) with initial postoperative paralysis. Facial nerve paralysis persisted in the other child with initial postoperative paralysis. Overall, 6 of these 7 patients (85.7%) with persistent facial nerve dysfunction had follow-up of less than 1 month. All transient and permanent facial nerve dysfunction was in the distribution of the marginal mandibular nerve only. No statistically significant predictors of complications were identified.

Conclusions:

We report acceptable but not insignificant rates of marginal mandibular distribution facial nerve injury, poor scarring, wound infection, and recurrence following resection of cervicofacial nontuberculous mycobacterial lymphade nitis in children that must be discussed with patients and parents before operation. No presentation or operative variables predicted the complications.

Incidence of Plagiocephaly in Teens Born after “Back to Sleep” Campaign

Objective: Determine the incidence of positional plagiocephaly in teenagers born after the “Back to Sleep” Campaign but before orthotic helmet treatment became widely available.

Method: This is a cross-sectional analysis. Subjects were selected if they attended participating high schools and were born after 1992, which is when the “Back to Sleep” campaign began. Skull measurements, including transcranial diameter, circumference, length, and width, were taken. Cranial vault asymmetry and cephalic index were calculated for each participant.

Results: There were 411 participants in this study ranging from age 14 to 18 years old, with the average age of 16.3 years. The diagnosis of plagiocephaly was made if cranial vault asymmetry was >1 centimeter. Brachycephaly was diagnosed if the cephalic index was >0.90. The incidence of plagiocephaly based on the above criteria was 1.3% in females and 2.7% of males. The incidence of brachycephaly was 0.9% in females and 1.6% in males. Of those noted to have abnormal facial characteristics (telecanthus, frontal prominence), 40% had plagiocephaly and 6.7% had brachycephaly.

Conclusion: The incidence of plagiocephaly in teenagers is significantly lower than the 20% to 48% incidence found in infants in previous studies, suggesting a significant number of infants will outgrow it. Physicians must recognize plagiocephaly and gain insight into which patients might benefit from treatment and which will likely have resolution without intervention.

Incidence of Operative Endoscopy Findings in Recurrent Croup

Objective. Develop an evidence-based model for predicting operative endoscopy findings in patients with recurrent croup.

Study Design. Case series with chart review.

Setting. Tertiary care children’s hospital.

Subjects and Methods. Retrospective chart review was performed on 124 patients who received consultation for recurrent croup between 2000 and 2009. Direct laryngoscopy and bronchoscopy findings were categorized as normal, mildly abnormal (incidental findings or grade I subglottic stenosis), moderately abnormal (grade II subglottic stenosis), or severely abnormal (grade III-IV subglottic stenosis).

Results. Of 124 consultations for recurrent croup, 81 patients (average age 3.5 years) underwent operative endoscopy. Normal examinations occurred in 33 of 81 (41%). Abnormal findings were encountered with the following frequency: mildly abnormal, 40 of 81 (49%); moderately abnormal, 6 of 81 (7.5%); and severely abnormal, 2 of 81 (2.5%). Relative risk (RR) of either moderately abnormal or severely abnormal findings was increased for patients who had a history of previous intubation (RR = 9.8; P = .002), prematurity (RR = 6.4; P = .01), or inpatient consultation (RR = 5.3; P = .028). The rate of moderately or severely abnormal findings in patients without the risk factors of intubation and age younger than 1 year was 0 of 48 (0%; confidence interval, 0%-7.4%). Mild abnormalities in this group were encountered in 27 of 48 (56%).

Conclusion. Mild airway abnormalities are common in children with recurrent croup and cannot be ruled out based on history. In the absence the risk factors of previous intubation, age younger than 1 year, or inpatient consultation, the incidence of a significantly abnormal finding is quite low. A predictive model based on this evidence is discussed.

Perspectives on poststroke sexual issues and rehabilitation needs

PURPOSE

To study the perspectives and experiences of stroke survivors and partners of stroke survivors regarding sexual issues and perceived rehabilitation needs.

METHODS

Using semi-structured interviews, 15 stroke survivors and 14 partners of stroke survivors (median age of 65 years, range 29 to 85) provided information about sexual issues experienced after stroke and their perspectives on how to address sexual concerns in a rehabilitation setting. A qualitative thematic analysis was applied to transcribed interviews to identify and describe common themes within the data relevant to the aim of the study. A quantitative analysis was utilized to elucidate the frequency of themes by demographic characteristics that were not readily apparent using a qualitative method alone.

RESULTS

Seven themes were identified. Two related to the effects of stroke on sexual life: physical/functional changes and relationship changes. Five related to addressing sexual issues in the process of rehabilitation: (1) difficulty in patients and providers talking about sexual matters, (2) little to no discussion of poststroke sexuality, (3) need for tailoring education to an individual or couple's unique needs, (4) provider rapport and competence, and (5) timing of poststroke sexual education.

CONCLUSIONS

Poststroke sexual issues are complex and suggest the need for the development of a biopsychosocial model of education and treatment intervention. Rehabilitation programs need to evaluate the level of training and services provided to address poststroke sexual issues. Development of clinically useful poststroke sexual adjustment assessment tools and interventions is warranted.

Animated video vs pamphlet: comparing the success of educating parents about proper antibiotic use

OBJECTIVE

The objective was to create an animated video to teach parents about the appropriate use of antibiotics and to compare their knowledge to parents who were provided with the American Academy of Pediatrics pamphlet. We hypothesized that the video format would result in improved comprehension and retention.

METHODS

This prospective randomized, controlled trial was conducted in an urban pediatric emergency department. Parent subjects were randomly assigned to a control group, a pamphlet group, and a video group and completed a survey at 3 time points. Analysis included the nonparametric matched Friedman test, Kruskal-Wallis test, and the Mann-Whitney U test. A 2-sided P value of < .05 was required for significance, and a Bonferroni-corrected P value of < .017 was required for paired comparisons.

RESULTS

Postintervention survey scores improved significantly in the pamphlet and video groups compared with baseline. The video group's follow-up scores were not significantly different from the postintervention-survey scores (P = .32). The pamphlet-group scores at follow-up were significantly lower than the postintervention-survey scores (P = .002). The control group's scores were similar at all 3 time periods. The pamphlet group had significantly better scores than the control group after the intervention (P < .001). The video-group scores exceeded the control-group scores at all 3 time periods.

CONCLUSIONS

An animated video is highly effective for educating parents about the appropriate use of antibiotics in the emergency department setting and results in long-term knowledge retention. The results of this study provide a foundation to further evaluate the use of animated video in additional populations.

Sensitivity of the pediatric early warning score to identify patient deterioration

OBJECTIVE

We evaluated the Pediatric Early Warning Score (PEWS) sensitivity as an early indicator of patients deterioration leading to a Rapid Response Team (RRT)/code event. We hypothesized that at least 80% of patients had a critical PEWS preceding the event. We determined staff awareness of deterioration in patient status prior to the event as evidenced by consults, addition of monitoring equipment or increased frequency of assessment. The timing of these events was compared to critical PEWS times.

METHODS

One hundred and seventy non-ICU RRT and 16 code events were identified between October 2006 and February 2008. We completed retrospective PEWS at four-hour intervals or less for twenty-four hours preceding the event. The PEWS algorithm, guiding staff to consult at a critical score > or =4 or a single domain score equal to 3, was applied.

RESULTS

For 85.5% of patients the earliest indicator of deterioration, evidenced by a critical PEWS, was a median of 11 hours 36 minutes and the earliest preceding the event was 30 minutes. For 97.1% of patients the earliest median time to a consult was 80 minutes. Oximetry was added 6.9 hours for 43.5% of patients. 7% of patients had increased nursing assessment. A sub-group of patients had 1) critical PEWS, 2) consult and 3) addition of a monitor. The median time for earliest critical PEWS for these was significant (P < 0.001).

CONCLUSION

PEWS can potentially provide a forewarning time >11 hours, alerting the team to adapt the care plan and possibly averting an RRT or code.

Cofermentation of glucose, xylose, and arabinose by mixed cultures of two genetically engineered Zymomonas mobilis strains

Cofermentation of xylose and arabinose, in addition to glucose, is critical for complete bioconversion of lignocellulosic biomass, such as agricultural residues and herbaceous energy crops, to ethanol. A factorial design experiment was used to evaluate the cofermentation of glucose, xylose, and arabinose with mixed cultures of two genetically engineered Zymomonas mobilis strains (one ferments xylose and the other arabinose). The pH range studied was 5.0-6.0, and the temperature range was 30-37 degrees C. The individual sugar concentrations used were 30 g/L glucose, 30 g/L xylose, and 20 g/L arabinose. The optimal cofermentation conditions obtained by data analysis, using Design Expert software, were pH 5.85 and temperature 31.5 degrees C. The cofermentation process yield at optimal conditions was 72.5% of theoretical maximum. The results showed that neither the arabinose strain nor arabinose affected the performance of the xylose strain; however, both xylose strain and xylose had a significant effect on the performance of the arabinose strain. Although cofermentation of all three sugars is achieved by the mixed cultures, there is a preferential order of sugar utilization. Glucose is used rapidly, then xylose, followed by arabinose.

Symptom duration and CT findings in pediatric deep neck infection

Objective: To investigate whether children with less than 48 hours of localized symptoms of deep neck infection are less likely to have an abscess on CT scan.

Study Design: Case series.

Subjects and Methods: The charts of children seen in a tertiary children's hospital for deep neck infections between 2000 and 2007 were reviewed.

Results: Of 179 children identified, 167 (93.3%) underwent a CT scan of the neck of which 102 (61.1%) were positive for abscess. There was no significant difference in the rate of abscess on CT between children with less than 48 hours of localizing symptoms and 48 or more hours of symptoms at 58.1 percent and 58.3 percent, respectively ( P = 0.98). Furthermore, there was no significant difference in age, gender, C-reactive protein levels, disease location, or length of stay between children with and without abscess on CT. White blood cell counts were significantly higher in the abscess group ( P = 0.01); however, the median white blood cell count in both groups was above normal.

Conclusion: Because duration of symptoms does not predict finding of abscess on CT, it is appropriate to obtain a CT scan upon presentation in all children with symptoms concerning for neck abscess.

Sinus surgery in cystic fibrosis patients: comparison of sinus and lower airway cultures

OBJECTIVE

The aim of this study is to determine whether cross-infection occurs between infections in the sinuses and lower airways in Cystic Fibrosis patients, and to determine whether the infections begin in the sinuses before spreading to the lungs.

METHODS

Retrospective study of pediatric Cystic Fibrosis patients who underwent simultaneous sinus surgery and bronchial washings. The results of the cultures were reviewed to determine if the same organisms colonized both the sinuses and lower airways.

RESULTS

Staphylococcus aureus (Staph. Aureus) was found in 40.7% of the sinuses but only 33.3% of the lower airways. One patient had Staph. Aureus in the lower airway but not the sinuses. Pseudomonas, Hemophilus Influenza, and Moraxella showed similar patterns: multiple instances of positive sinus cultures and negative bronchial cultures, but only a small number of cases with positive lower airway cultures and negative sinus cultures.

CONCLUSION

The data showed that as patients age, they are more likely to have infections in both upper and lower airways, but infections start in the upper airways at a younger age. In many cases, organisms were cultured from sinuses in patients who had negative lower airway cultures. In only a few instances, organisms grew in the lower airways and not the sinuses. In most cases, the bacteria that caused sinus infections at a young age caused the lung infections in older patients. This is the paper to show that bacteria spread from the sinuses to the lungs to cause infections in Cystic Fibrosis patients, and not vice-versa.

Symptom Duration and CT Findings in Pediatric Neck Infection

Objective

To test the hypothesis that children with less than 48 hours of localized symptoms of deep space neck infections are less likely to have an abscess on CT than children with at least 48 hours of localized symptoms.

Methods

Children seen in a tertiary hospital between 2000 and 2007 with infections of the head and neck region, excluding peritonsillar abscess, were identified. Data regarding presentation, physical exam findings, radiographic findings, and treatment were extracted.

Results

Of 179 children identified, 167 (93.3%) underwent a CT scan of the neck, of which 102 (61.1%) were positive for abscess. The median duration of symptoms in children with and without abscess on CT were the same (48 hours). There was no significant difference in the rate of abscess on CT between children with less than 48 hours of localizing symptoms and 48 or more hours of symptoms at 58.1% and 57.7% respectively (p=0.96). Furthermore, there were no significant difference in gender, C-reactive protein levels, or disease location between children with and without abscess on CT. White blood cell counts were significantly higher in the abscess group (p=0.01), however the median white blood cell count in both groups was above normal.

Conclusions

Because duration of symptoms does not predict finding of abscess on CT scan in pediatric deep neck space infections, it is appropriate to obtain a CT scan upon presentation in all children with symptoms concerning for deep neck space abscess.

Hoarseness in Children with Cleft Palate

Objective

1) To determine the rate of hoarseness in children with cleft palate (CP). 2) To understand the relationship between velopharyngeal insufficiency (VPI) and hoarseness in children with CP.

Methods

Retrospective chart review of 98 patients treated for CP by a tertiary care Children's Hospital Cleft Team and born between 1990 and 2001.

Results

Of the 98 patients, 59 were male and 39 female. All types of CP were represented. 89% received speech therapy. 41.6% had VPI. The overall rate of hoarseness was 22.4% and of dysphonia was 55.9%. The presence of VPI did not correlate with the presence of hoarseness or dysphonia. However, while VPI decreased when comparing ages 3–4 (58.1%) with ages 6–7 (32.1%) (p <0.001), the hoarseness rates did not change as children got older. Additionally, there was a trend toward higher hoarseness and dysphonia rates in children with Pierre Robin Syndrome (PRS).

Conclusions

Both VPI and hoarseness are common findings in patients with CP. VPI improves as children get older in the setting of a tertiary care cleft team and a high rate of speech therapy. However, hoarseness and dysphonia do not appear to improve. These findings suggest that the theory that VPI causes hoarseness due to compensatory speech mechanisms may be incorrect. Even when resonance problems have improved, CP patients should continue to be evaluated by speech therapists for voice disturbances, as well as evaluated by otolaryngologists for treatable causes of hoarseness. Further, patients with PRS may be at additional risk for voice disturbances and should be treated accordingly.

The impact of positioning on fear during immunizations: supine versus sitting up

This study explored the impact of a child's position on the level of fear and perception of pain during an immunization injection. One hundred seven children, ages 4-6, participated in a random-assignment, two-group design study to evaluate the effect of positioning on fear and perceived pain. Group 1 was placed in the supine position and Group 2 in the sitting position prior to immunizations. The results substantiated the belief that children are significantly less fearful about receiving an injection when they are sitting up as compared to when they are lying down. There was no difference in perception of pain.

Adapting to changes in molecular biosciences and technologies

Dental education, like any other educational programme in a research-intensive university environment, must be research led or at least research informed. In this context, as the research and knowledge base of dentistry lies in the biological and physical sciences, dental education must be led by advances in research in both these areas. There is no doubt that biotechnology and nanotechnology have, over the past 25 years, led research in both these areas. It is therefore logical to assume that this has also impacted on dental education. The aim of this paper is twofold; on one hand to examine the effects of biotechnology and nanotechnology and their implications for dental education and on the other to make recommendations for future developments in dental education led by research in biotechnology and nanotechnology. It is now generally accepted that dental education should be socially and culturally relevant and directed to the community it serves. In other words, there can be no universal approach and each dental school or indeed curriculum must apply the outcomes in their own social, cultural and community settings.

Creation of a registered nurse-administered nitrous oxide sedation program for radiology and beyond

Children undergoing urethral catheterization for urologic imaging under existing sedation practices were identified as an underserved patient population. Using a multidisciplinary approach, a registered nurse (RN)-administered nitrous oxide sedation program was developed to meet the needs of these children. Program development required delineation of RN scope of practice, evaluation of equipment, formulation of an educational program, and compliance with occupational safety standards. The program was implemented in 2004 using standard "dental" nitrous oxide equipment coupled with distraction and imagery to enhance the efficacy of the sedation experience. Initial assessment via telephone questionnaire indicated fewer adverse effects and more rapid return to baseline than oral midazolam, the sedative previously used for these procedures. Ongoing evaluation continues to confirm patient and environmental safety. The nitrous oxide program has expanded to provide sedation for additional tests in radiology as well as in other hospital departments. By implementing an RN-administered nitrous oxide program, children's access to this sedative/analgesic agent is increased.

Propofol sedation: intensivists' experience with 7304 cases in a children's hospital

OBJECTIVE

The objective of this study was to determine the safety profile of propofol as a deep-sedation agent in a primarily outpatient program consisting of pediatric critical care physicians and specifically trained nurses with oversight provided by anesthesiology. One hypothesis was investigated: adverse events and/or airway interventions are more likely to occur in children with an abnormal airway score.

METHODS

A 36-month dual-site prospective, observational, clinical study was conducted in a single center with interchangeable providers operating within the guidelines of a single sedation program. A total of 7304 propofol sedations for 4464 unique patients who ranged in age from 1 month to 21 years were studied; >97% of the children were >1 year of age.

RESULTS

The following adverse reactions were identified, and a descriptive statistical analysis of the data were performed: mild oxygen desaturation (85%-90%), 1.73%; serious oxygen desaturation (<85%), 2.9%; laryngospasm, 0.27%; regurgitation without aspiration, 0.05%; regurgitation with aspiration, 0.01%; bronchospasm, 0.15%; and hypotension, 31.4%. Interventions required included oral airway, 0.96%; nasal trumpet, 1.57%; rescue breaths for >1 minute, 0.37%; intubation, 0.03%; volume requirement of >40 mL/kg per hour, 0.11%; sedation-induced ward or PICU admission, 0.04%; cardiac arrest medications, 0%; and aborted sedation or procedure, 0%. We devised an airway score to identify at-risk patients. Patients with an abnormal airway score were significantly more likely to: have oxygen desaturation (13.1% vs 4.3%); require an oral airway (5.9% vs 0.8%); and require a nasal trumpet (13.9% vs 1.2%).

CONCLUSIONS

Propofol has an acceptable safety profile for deep sedation when used in the context of a program with critical care physicians, specifically trained nurses, and anesthesiology oversight. A preprocedure airway score can assist in identifying patients who may require airway interventions.

Cerebral metastasis and other central nervous system complications of pleuropulmonary blastoma

BACKGROUND

Pleuropulmonary blastoma (PPB) is a rare tumor of pleura and lung in young children. Central nervous system (CNS) complications, particularly cerebral parenchymal metastases, occur in aggressive forms of PPB: Types II and III PPB. This article evaluates cerebral and meningeal metastases, cerebrovascular events (CVA) caused by tumor emboli, spinal cord complications, and intracranial second malignancies in PPB.

PROCEDURE

International PPB Registry and literature cases were evaluated for CNS events. Cerebral metastasis patients were evaluated for gender, side of origin of PPB, PPB Type, interval from diagnosis to metastasis, status of chest disease, treatment, and outcome. Standard statistical methods were used to calculate the cumulative probability of cerebral metastasis and survival following metastasis.

RESULTS

Thirty-nine cases of cerebral metastasis were identified in 5/53 Registry Type II cases, 15/44 Registry Type III cases, and 19/143 literature Type II/III cases. Metastases occurred 1-60, median 11.5 months after diagnosis. Chest disease was controlled in 50% of children at time of metastasis. The cumulative probability of cerebral metastasis by 5 years from diagnosis was 11% for Type II patients (95%CI (confidence interval): 2-20%) and 54% for Type III patients (95%CI: 31-76%). Seven children survive cerebral metastasis. Other CNS complications were post-operative CVA (five cases), spinal cord invasion or compression (six), leptomeningeal disease (three), and second intracranial malignancies (two).

CONCLUSIONS

Cerebral metastasis is more frequent in PPB than in other childhood sarcomas. Clinicians should screen for this complication. Diverse other CNS complications are less common and require careful diagnosis.

Sedation with nitrous oxide compared with no sedation during catheterization for urologic imaging in children

BACKGROUND

Various strategies to mitigate children's distress during voiding cystourethrography (VCUG) have been described. Sedation with nitrous oxide is comparable to that with oral midazolam for VCUG, but a side-by-side comparison of nitrous oxide sedation and routine care is lacking.

OBJECTIVE

The effects of sedation/analgesia using 70% nitrous oxide and routine care for VCUG and radionuclide cystography (RNC) were compared.

MATERIALS AND METHODS

A sample of 204 children 4-18 years of age scheduled for VCUG or RNC with sedation or routine care were enrolled in this prospective study. Nitrous oxide/oxygen (70%/30%) was administered during urethral catheterization to children in the sedated group. The outcomes recorded included observed distress using the Brief Behavioral Distress Score, self-reported pain, and time in department.

RESULTS

The study included 204 patients (99 nonsedated, 105 sedated) with a median age of 6.3 years (range 4.0-15.2 years). Distress and pain scores were greater in nonsedated than in sedated patients (P < 0.001). Time in department was longer in the sedated group (90 min vs. 30 min); however, time from entry to catheterization in a non-imaging area accounted for most of the difference. There was no difference in radiologic imaging time.

CONCLUSION

Sedation with nitrous oxide is effective in reducing distress and pain during catheterization for VCUG or RNC in children.

Implementation and Impact of a Rapid Response Team in a Children’s Hospital

Like the previous two studies of RRS implementation in a children's hospital, this study--the first to use an RRT model--showed a decrease in the incidence of arrests (although not at a significant level). Low mortality rates and infrequent arrests in children's hospitals make changes in these measures insensitive indicators of the positive impact of RRT implementation. RRTs provide an immediate response for children whose clinical condition is worrisome and whose attending physicians are not immediately present. Children receive significant care through the RRT, and nurse response is very favorable to having access to fast, dependable, and knowledgeable backup 24 hours a day. The RRT program is a vital component of the safety net for children's hospitals, and RRT data provides an avenue for quality improvement efforts and further research.

The Effect of Gender and Ethnicity on Children’s Attitudes and Preferences for Essential Oils: A Pilot Study

CONTEXT

Aromatherapy is frequently recommended for children but children's preferences for specific essential oils are not well documented.

OBJECTIVE

To measure preferences of school aged children for essential oils based on gender and ethnicity.

DESIGN

Descriptive study measuring children's responses to and preferences for selected essential oils.

SETTING

Pediatric integrative medicine clinic in a Midwestern children's hospital.

PARTICIPANTS

Healthy school-age children of Latino (N = 39) and non-Latino Caucasian (NLC) (N = 48) ethnicity, 41.7% of the NLC group and 59.0% of the Latino Group were males.

INTERVENTION

Participants smelled single essential oils, answered three forced choice questions and one open ended question, order of exposure was varied.

OUTCOME MEASURES

Participants evaluated each scent's effect on mood and energy, stated their preferences, indicated if scents evoked particular thoughts and selected a favorite essential oil.

RESULTS

Females were more likely to feel happy when smelling sweet orange (p = .043). Female Latinos were more likely than NLC females to find sweet orange calming (56.2% vs. 18.5%). Male Latinos were more likely (65.2%) to describe peppermint as "energetic" than male NLC (30%). Children chose an essential oil that they rated as "making them feel happy" (72.6%) and/or as "liking the most" (64.3%). Other results that approached statistical significance were: females felt more energetic with spearmint (p = .055). Latinos preferred spearmint over NLC (p = .075), and all males felt more energetic when smelling ginger (p = .091). Ginger and lavender were the least preferred. Results indicate that children have specific essential oil scent preferences. There is trend toward differences based on gender and ethnicity.

Safety of transdermal scopolamine in pediatric patients for chemotherapy-induced nausea and vomiting (CINV)

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Background: Transdermal scopolamine has been used for over 25 years in the treatment of nausea and vomiting, but little information is available on its safety in pediatric patients. The antiemetic guidelines established at our hospital allow children between 8 and 15kg to receive a ½ patch every 3 days and children greater than 15 kg to receive 1 patch every 3 days as an adjunct agent for CINV. The goal of this study was to assess the safety of transdermal scopolamine in hospitalized pediatric patients during chemotherapy treatment. Methods: A retrospective chart review was conducted at Children’s Hospital and Clinics of Minnesota from April to September 2005. A total of 82 hospital admissions (41 patients) were reviewed for adverse effects specific to scopolamine using the National Cancer Institute’s Common Terminology Criteria for Adverse Events. Results: Mean patient age was 8 years (1–20 years) and the average length of patch use was 6 days (2–31 days). Of the 82 admissions reviewed, a total of 20 adverse events occurred (24%) in 14 patients. Median weight was significantly greater for patients experiencing the following adverse events compared to patients that did not: headaches (p=0.009), mental status changes (p=0.01) and hallucinations (p=0.003). Age > 12 years (p<0.001) and use of the patch > 4 days (p<0.01) were significantly correlated with the incidence of an adverse event. 75% of patients did not experience an adverse effect from transdermal scopolamine therapy when used 4 days or less. Conclusions: Transdermal scopolamine is a safe adjuvant for treatment of CINV in pediatric patients; however, as many as 1 in 5 may suffer adverse events. When used for more than 4 days the risk of adverse events increases. Older children and adolescents are more prone to adverse events.

No significant financial relationships to disclose.

Gender differences in attitudes toward AIDS clinical trials among urban HIV-infected individuals from racial and ethnic minority backgrounds

Racial/ethnic minorities and women are under-represented in AIDS clinical trials (ACTs). We examined gender differences in willingness to participate in ACTs among urban HIV-infected individuals (N = 286). Sixty percent of participants were male, and most were from racial/ethnic minority backgrounds (55% African-American, 34% Latino/Hispanic, 11% White/other). Knowledge of ACTs was poor. Males and females did not differ substantially in their distrust of AIDS scientists, or in barriers to ACTs. Almost all (87%) were somewhat or very willing to join ACTs. Females were less willing than males to join, including trials testing new medications or new medication combinations. Males and females differed in correlates of willingness to participate in ACTs. Despite long-standing barriers to medical research among minorities and women, willingness to participate was substantial, particularly for men, although the factors that might motivate them to join differed by gender. Women appeared more averse to trials involving new anti-retroviral regimens than men. Gender-specific outreach, behavioural intervention, and social marketing efforts are needed.

Reduction of bronchopulmonary dysplasia after participation in the Breathsavers Group of the Vermont Oxford Network Neonatal Intensive Care Quality Improvement Collaborative

OBJECTIVE

The objective of this study was to compare the primary and secondary outcomes of very low birth weight infants before and after participation in the Breathsavers Group of the Vermont Oxford Network-sponsored Neonatal Intensive Care Quality Collaborative.

METHODS

Hospitals that participated in the Breathsavers Group contributed clinical data on the outcomes of their very low birth weight infants to the Vermont Oxford Network using standardized clinical definitions, data forms, and inclusion criteria. Outcomes from the last year of the collaborative, 2003, were compared with those from the baseline year, 2001. Models for treatment practices and outcomes measures were adjusted for within-hospital correlation (clustering) and standard risk factors that were present at birth.

RESULTS

Bronchopulmonary dysplasia dropped significantly in 2003 compared with the baseline year. Survival improved but not significantly. In addition, severe retinopathy of prematurity, severe intraventricular hemorrhage, and supplemental oxygen at discharge dropped significantly. The use of conventional ventilation at any time during the initial hospitalization, postnatal steroids, and time to first dose of surfactant all decreased significantly. The use of nasal continuous positive airway pressure at any time during hospitalization increased. The use of high-frequency ventilation, delivery room intubation, and surfactant at any time during hospitalization did not change.

CONCLUSIONS

The Breathsavers Group improved both clinical care processes and clinical outcomes during the Neonatal Intensive Care Quality Collaborative.

Cri du chat syndrome and congenital heart disease: a review of previously reported cases and presentation of an additional 21 cases from the Pediatric Cardiac Care Consortium

OBJECTIVES

To analyze the cases submitted to the Pediatric Cardiac Care Consortium (PCCC) database from 1982 to 2002 to determine the frequency and distribution of congenital heart disease (CHD) found in this population, to review the literature for previously published accounts of CHD in this population, and to review current genotype-phenotype associations for cri du chat (CDC) syndrome with CHD.

METHODS

We performed a retrospective review of the 98422 CHD cases submitted to the PCCC between 1982 and 2002, to find patients who had a noncardiac diagnosis of CDC syndrome.

RESULTS

A total of 21 patients (15 female and 6 male patients) were identified. Although some patients had multiple cardiac anomalies, they were categorized according to primary diagnoses on the basis of the most hemodynamically significant component. The patient groups were ventricular septal defect (n = 6), patent ductus arteriosus (n = 6), tetralogy of Fallot (n = 5), pulmonary valve atresia with ventricular septal defect (n = 2), pulmonary valve stenosis (n = 1), and double-outlet right ventricle (n = 1). Eighteen of the 21 patients underwent surgical repair of their defects. There was 1 late operative death. To determine whether the observed frequency of these cardiac defects among patients with CDC syndrome was comparable to that of the general population of patients with CHD, data for all cases submitted to the PCCC from 1982 to 2002 were used. Use of these numbers to determine expected frequencies for these defects showed significantly greater proportions of patients with these specific lesions among the patients with CDC syndrome.

CONCLUSIONS

Currently there is no clear understanding of the genomic cause of the prevalence of these defects in the population with CDC syndrome, although CHD has been noted among patients with other deletion syndromes.