1
|
Shapiro DJ, Hall M, Ramgopal S, Alpern ER, Chaudhari PP, Eltorki M, Badaki-Makun O, Bergmann KR, Macy ML, Foster CC, Neuman MI. Acute care utilization for ambulatory care-sensitive conditions among publicly insured children. Acad Emerg Med 2024; 31:346-353. [PMID: 38385565 PMCID: PMC11014776 DOI: 10.1111/acem.14867] [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] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2023] [Revised: 12/01/2023] [Accepted: 12/27/2023] [Indexed: 02/23/2024]
Abstract
BACKGROUND Although characteristics of preventable hospitalizations for ambulatory care-sensitive conditions (ACSCs) have been described, less is known about patterns of emergency and other acute care utilization for ACSCs among children who are not hospitalized. We sought to describe patterns of utilization for ACSCs according to the initial site of care and to determine characteristics associated with seeking initial care in an acute care setting rather than in an office. A better understanding of the sequence of health care utilization for ACSCs may inform efforts to shift care for these common conditions to the medical home. METHODS We performed a retrospective analysis of pediatric encounters for ACSCs between 2017 and 2019 using data from the IBM Watson MarketScan Medicaid database. The database includes insurance claims for Medicaid-insured children in 10 anonymized states. We assessed the initial sites of care for ACSC encounters, which were defined as either acute care settings (emergency or urgent care) or office-based settings. We used generalized estimating equations clustered on patient to identify associations between encounter characteristics and the initial site of care. RESULTS Among 7,128,515 encounters for ACSCs, acute care settings were the initial site of care in 27.9%. Diagnoses with the greatest proportion of episodes presenting to acute care settings were urinary tract infection (52.0% of episodes) and pneumonia (44.6%). Encounters on the weekend (adjusted odds ratio [aOR] 6.30, 95% confidence interval [CI] 6.27-6.34 compared with weekday) and among children with capitated insurance (aOR 1.55, 95% CI 1.54-1.56 compared with fee for service) were associated with increased odds of seeking care first in an acute care setting. CONCLUSIONS Acute care settings are the initial sites of care for more than one in four encounters for ACSCs among publicly insured children. Expanded access to primary care on weekends may shift care for ACSCs to the medical home.
Collapse
Affiliation(s)
- Daniel J Shapiro
- Division of Pediatric Emergency Medicine, University of California, San Francisco, San Francisco, California, USA
| | - Matt Hall
- Children's Hospital Association, Lenexa, Kansas, USA
| | - Sriram Ramgopal
- Division of Emergency Medicine, Department of Pediatrics, Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Elizabeth R Alpern
- Division of Emergency Medicine, Department of Pediatrics, Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Pradip P Chaudhari
- Division of Emergency and Transport Medicine, Children's Hospital Los Angeles, Department of Pediatrics, Keck School of Medicine of the University of Southern California, Los Angeles, California, USA
| | - Mohamed Eltorki
- Division of Pediatric Emergency Medicine, Department of Pediatrics, McMaster Children's Hospital, McMaster University, Hamilton, Ontario, Canada
| | - Oluwakemi Badaki-Makun
- Division of Pediatric Emergency Medicine, Department of Pediatrics, Johns Hopkins University School of Medicine, Center for Data Science in Emergency Medicine, Johns Hopkins University, Baltimore, Maryland, USA
| | - Kelly R Bergmann
- Department of Pediatric Emergency Medicine, Children's Hospital Minnesota, South Minneapolis, Minnesota, USA
| | - Michelle L Macy
- Division of Emergency Medicine, Department of Pediatrics, Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Carolyn C Foster
- Division of Advanced Pediatrics and Primary Care, Ann & Robert H. Lurie Children's Hospital of Chicago and Northwestern University, Chicago, Illinois, USA
| | - Mark I Neuman
- Division of Emergency Medicine, Boston Children's Hospital, Boston, Massachusetts, USA
- Department of Pediatrics, Harvard Medical School, Boston, Massachusetts, USA
| |
Collapse
|
2
|
Grandjean-Blanchet C, Eltorki M, Strickland M, Kang A, Wen A, Rosenfield D. Evaluating Multiple Magnet Ingestion at 2 Large Canadian Pediatric Hospitals After Reintroduction to the US Marketplace. Pediatr Emerg Care 2024; 40:214-217. [PMID: 37083691 DOI: 10.1097/pec.0000000000002948] [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] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/22/2023]
Abstract
OBJECTIVES To determine the trend in incidence of pediatric magnet ingestions at 2 large Canadian tertiary pediatric hospitals after reintroduction of magnets to the US marketplace and to evaluate morbidity and mortality related to these ingestions. METHODS This was a retrospective study performed in 2 tertiary care pediatric hospitals between 2004 and 2019. We reviewed the charts of all children who presented with a foreign body ingestion and included those with reported magnet ingestion. We characterized all events and compared the incidence rate before and after the US ban was overturned in 2016. Descriptive statistics were used to summarize our results. Incidence rate ratio was calculated using the total number of magnet ingestion cases and total emergency department visits normalized to 100,000 emergency department visits/year. RESULTS We screened a total of 6586 ingestions and identified 192 patients with magnet ingestions. The period after the mandatory recall was compared with the period after the US ban revocation yielding an incidence rate ratio of 0.76 for all magnet ingestions ( P = 0.15) and 0.73 ( P = 0.34) for multiple magnet ingestions. There was, however, a graphical upward trend that immediately followed the US ban revocation. Sixty-nine patients (36%) were admitted to the hospital and 45 (23%) required a procedure to remove the magnet ingested. No deaths occurred. CONCLUSIONS Our findings suggest that the overturning of the US ban did not lead to a significant increase in the incidence of rare earth magnet ingestion in 2 large tertiary pediatric hospitals in Canada despite noting a trend upwards.
Collapse
Affiliation(s)
| | - Mohamed Eltorki
- McMaster Children's Hospital, Faculty of Health Sciences, McMaster University, Hamilton, Ontario, Canada
| | - Matt Strickland
- Department of Surgery, University of Alberta, Edmonton, Alberta, Canada
| | | | - Aaron Wen
- McMaster Children's Hospital, Faculty of Health Sciences, McMaster University, Hamilton, Ontario, Canada
| | | |
Collapse
|
3
|
Sharif S, Kang J, Sadeghirad B, Rizvi F, Forestell B, Greer A, Hewitt M, Fernando SM, Mehta S, Eltorki M, Siemieniuk R, Duffett M, Bhatt M, Burry L, Perry JJ, Petrosoniak A, Pandharipande P, Welsford M, Rochwerg B. Pharmacological agents for procedural sedation and analgesia in the emergency department and intensive care unit: a systematic review and network meta-analysis of randomised trials. Br J Anaesth 2024; 132:491-506. [PMID: 38185564 DOI: 10.1016/j.bja.2023.11.050] [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] [Subscribe] [Scholar Register] [Received: 08/07/2023] [Revised: 09/29/2023] [Accepted: 11/30/2023] [Indexed: 01/09/2024] Open
Abstract
BACKGROUND We aimed to evaluate the comparative effectiveness and safety of various i.v. pharmacologic agents used for procedural sedation and analgesia (PSA) in the emergency department (ED) and ICU. We performed a systematic review and network meta-analysis to enable direct and indirect comparisons between available medications. METHODS We searched Medline, EMBASE, Cochrane, and PubMed from inception to 2 March 2023 for RCTs comparing two or more procedural sedation and analgesia medications in all patients (adults and children >30 days of age) requiring emergent procedures in the ED or ICU. We focused on the outcomes of sedation recovery time, patient satisfaction, and adverse events (AEs). We performed frequentist random-effects model network meta-analysis and used the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) approach to rate certainty in estimates. RESULTS We included 82 RCTs (8105 patients, 78 conducted in the ED and four in the ICU) of which 52 studies included adults, 23 included children, and seven included both. Compared with midazolam-opioids, recovery time was shorter with propofol (mean difference 16.3 min, 95% confidence interval [CI] 8.4-24.3 fewer minutes; high certainty), and patient satisfaction was better with ketamine-propofol (mean difference 1.5 points, 95% CI 0.3-2.6 points, high certainty). Regarding AEs, compared with midazolam-opioids, respiratory AEs were less frequent with ketamine (relative risk [RR] 0.55, 95% CI 0.32-0.96; high certainty), gastrointestinal AEs were more common with ketamine-midazolam (RR 3.08, 95% CI 1.15-8.27; high certainty), and neurological AEs were more common with ketamine-propofol (RR 3.68, 95% CI 1.08-12.53; high certainty). CONCLUSION When considering procedural sedation and analgesia in the ED and ICU, compared with midazolam-opioids, sedation recovery time is shorter with propofol, patient satisfaction is better with ketamine-propofol, and respiratory adverse events are less common with ketamine.
Collapse
Affiliation(s)
- Sameer Sharif
- Department of Medicine, Division of Emergency Medicine, McMaster University, Hamilton, ON, Canada; Department of Medicine, Division of Critical Care, McMaster University, Hamilton, ON, Canada; Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, ON, Canada.
| | - Jasmine Kang
- Michael G. DeGroote School of Medicine, McMaster University, Hamilton, ON, Canada
| | - Behnam Sadeghirad
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, ON, Canada; Department of Anesthesia, McMaster University, Hamilton, ON, Canada
| | - Fayyaz Rizvi
- Michael G. DeGroote School of Medicine, McMaster University, Hamilton, ON, Canada
| | - Ben Forestell
- Department of Medicine, Division of Emergency Medicine, McMaster University, Hamilton, ON, Canada
| | - Alisha Greer
- Department of Medicine, Division of Emergency Medicine, McMaster University, Hamilton, ON, Canada; Department of Medicine, Division of Critical Care, McMaster University, Hamilton, ON, Canada
| | - Mark Hewitt
- Department of Medicine, Division of Emergency Medicine, McMaster University, Hamilton, ON, Canada; Department of Medicine, Division of Critical Care, McMaster University, Hamilton, ON, Canada
| | - Shannon M Fernando
- Department of Emergency Medicine, University of Ottawa, Ottawa, ON, Canada; Division of Critical Care, Department of Medicine, University of Ottawa, Ottawa, ON, Canada
| | - Sangeeta Mehta
- Department of Medicine, Sinai Health System; Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada
| | - Mohamed Eltorki
- Department of Pediatrics, Division of Pediatric Emergency Medicine, McMaster University, Ottawa, ON, Canada
| | - Reed Siemieniuk
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, ON, Canada; Department of Medicine, McMaster University, Hamilton, ON, Canada
| | - Mark Duffett
- Department of Pediatrics, McMaster University, Hamilton, ON, Canada
| | - Maala Bhatt
- Department of Medicine, Sinai Health System, Interdepartmental Division of Critical Care Medicine, Toronto, ON, Canada
| | - Lisa Burry
- Department of Medicine, Sinai Health System; Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada; Department of Pharmacy, Sinai Health System, Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, ON, Canada
| | - Jeffrey J Perry
- Department of Emergency Medicine, University of Ottawa, Ottawa, ON, Canada
| | - Andrew Petrosoniak
- Department of Medicine, Division of Emergency Medicine, University of Toronto, Toronto, ON, Canada
| | - Pratik Pandharipande
- Department of Anesthesiology, Division of Critical Care, Vanderbilt University School of Medicine, Nashville, TN, USA
| | - Michelle Welsford
- Department of Medicine, Division of Emergency Medicine, McMaster University, Hamilton, ON, Canada
| | - Bram Rochwerg
- Department of Medicine, Division of Critical Care, McMaster University, Hamilton, ON, Canada; Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, ON, Canada
| |
Collapse
|
4
|
Forestell B, Sabbineni M, Sharif S, Chao J, Eltorki M. Comparative Effectiveness of Ketorolac Dosing Strategies for Emergency Department Patients With Acute Pain. Ann Emerg Med 2023; 82:615-623. [PMID: 37178102 DOI: 10.1016/j.annemergmed.2023.04.011] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2023] [Revised: 04/04/2023] [Accepted: 04/10/2023] [Indexed: 05/15/2023]
Abstract
STUDY OBJECTIVES Ketorolac is a commonly used nonopioid parenteral analgesic for treating emergency department (ED) patients with acute pain. Our systematic review aims to summarize the available evidence by comparing the efficacy and safety of differing ketorolac dosing strategies for acute pain relief in the ED. METHODS The review was registered on PROSPERO (CRD42022310062). We searched MEDLINE, PubMed, EMBASE, and unpublished sources from inception through December 9, 2022. We included randomized control trials of patients presenting with acute pain to the ED, comparing ketorolac doses less than 30 mg (low dose) to ketorolac doses more than or equal to 30 mg (high dose) for the outcomes of pain scores after treatment need for rescue analgesia, and incidence of adverse events. We excluded patients in non-ED settings, including postoperative settings. We extracted data independently and in duplicate and pooled them using a random-effects model. We assessed the risk of bias using the Cochrane Risk of Bias 2 tool and the overall certainty of the evidence for each outcome using the Grading Recommendations Assessment, Development, and Evaluation approach. RESULTS This review included 5 randomized controlled trials (n=627 patients). Low-dose parenteral ketorolac (15 to 20 mg), as compared to high-dose ketorolac (≥30 mg), probably has no effect on pain scores (mean difference 0.05 mm lower on 100 mm visual analog scale, 95% confidence interval [CI] -4.91 mm to +5.01 mm; moderate certainty). Further, low-dose ketorolac at 10 mg may have no effect on pain scores compared to high-dose ketorolac (mean difference 1.58 mm lower on 100 mm visual analog scale, 95% CI -8.86 mm to +5.71 mm; low certainty). Low-dose ketorolac may increase the need for rescue analgesia (risk ratio 1.27, 95% CI 0.86 to 1.87; low certainty) and may have no difference on rates of adverse events (risk ratio 0.84, 95% CI 0.54 to 1.33; low certainty). CONCLUSION In adult ED patients with acute pain, parenteral ketorolac given at doses of 10 mg to 20 mg is probably as effective in relieving pain as doses of 30 mg or higher. Low-dose ketorolac may have no effect on adverse events, but these patients may require more rescue analgesia. This evidence is limited by imprecision and is not generalizable to children or those at higher risk of adverse events.
Collapse
Affiliation(s)
- Ben Forestell
- Division of Emergency Medicine, McMaster University, Hamilton, Ontario, Canada.
| | - Monica Sabbineni
- Department of Medicine, Michael G DeGroote Medical School, McMaster University, Hamilton, Ontario, Canada
| | - Sameer Sharif
- Division of Critical Care, McMaster University, Hamilton, Ontario, Canada; Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Ontario, Canada
| | - Jennifer Chao
- Department of Emergency Medicine, Faculty of Medicine, University of British Columbia, Vancouver and Royal Columbian Hospital, New Westminster, British Columbia, Canada
| | - Mohamed Eltorki
- Department of Pediatrics, McMaster Children's Hospital, Faculty of Health Sciences, McMaster University, Hamilton, Ontario, Canada
| |
Collapse
|
5
|
Schuh S, Coates AL, Sweeney J, Rumantir M, Eltorki M, Alqurashi W, Plint AC, Zemek R, Poonai N, Parkin PC, Soares D, Moineddin R, Finkelstein Y. Nasal Suctioning Therapy Among Infants With Bronchiolitis Discharged Home From the Emergency Department: A Randomized Clinical Trial. JAMA Netw Open 2023; 6:e2337810. [PMID: 37856126 PMCID: PMC10587796 DOI: 10.1001/jamanetworkopen.2023.37810] [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] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/05/2023] [Accepted: 08/18/2023] [Indexed: 10/20/2023] Open
Abstract
Importance Although nasal suctioning is the most frequently used supportive management for bronchiolitis, its benefit remains unknown. Objective To evaluate the effectiveness of enhanced vs minimal nasal suctioning in treating infants with bronchiolitis after discharge from the emergency department (ED). Design, Setting, and Participants This single-blind, parallel-group, randomized clinical trial was conducted from March 6, 2020, to December 15, 2022, at 4 tertiary-care Canadian pediatric EDs. Participants included otherwise healthy infants aged 1 to 11 months with a diagnosis of bronchiolitis who were discharged home from the ED. Interventions Participants were randomized to minimal suctioning via bulb or enhanced suctioning via a battery-operated device before feeding for 72 hours. Main Outcomes and Measures The primary outcome was additional resource use, a composite of unscheduled revisits for bronchiolitis or use of additional suctioning devices for feeding and/or breathing concerns. Secondary outcomes included health care utilization, feeding and sleeping adequacy, and satisfaction. Results Of 884 screened patients, 352 were excluded for criteria, 79 declined participation, 81 were otherwise excluded, 372 were randomized (185 to the minimal suction group and 187 to the enhanced suction group), and 367 (median [IQR] age, 4 [2-6] months; 221 boys [60.2%]) completed the trial (184 in the minimal suction and 183 in the enhanced suction group). Additional resource use occurred for 68 of 184 minimal suction participants (37.0%) vs 48 of 183 enhanced suction participants (26.2%) (absolute risk difference, 0.11; 95% CI, 0.01 to 0.20; P = .03). Unscheduled revisits occurred for 47 of 184 minimal suction participants (25.5%) vs 40 of 183 enhanced suction participants (21.9%) (absolute risk difference, 0.04; 95% CI, -0.05 to 0.12; P = .46). A total of 33 of 184 parents in the minimal suction group (17.9%) used additional suctioning devices vs 11 of 183 parents in the enhanced suction group (6.0%) (absolute risk difference, 0.12; 95% CI, 0.05 to 0.19; P < .001). No significant between-group differences were observed for all bronchiolitis revisits (absolute risk difference, 0.07; 95% CI, -0.02 to 0.16; P = .15), ED revisits (absolute risk difference, 0.04; 95% CI, -0.03 to 0.12; P = .30), parental care satisfaction (absolute risk difference, -0.02; 95% CI, -0.10 to 0.06; P = .70), and changes from baseline to 72 hours in normal feeding (difference in differences, 0.03; 95% CI, -0.10 to 0.17; P = .62), normal sleeping (difference in differences, 0.05; 95% CI, -0.08 to 0.18; P = .47), or normal parental sleeping (difference in differences, 0.10; 95% CI, -0.02 to 0.23; P = .09). Parents in the minimal suction group were less satisfied with the assigned device (62 of 184 [33.7%]) than parents in the enhanced suction group (145 of 183 [79.2%]) (risk difference, 0.45; 95% CI, 0.36 to 0.54; P < .001). Conclusions and Relevance Compared with minimal suctioning, enhanced suctioning after ED discharge with bronchiolitis did not alter the disease course because there were no group differences in revisits or feeding and sleeping adequacy. Minimal suctioning resulted in higher use of nonassigned suctioning devices and lower parental satisfaction with the assigned device. Trial Registration ClinicalTrials.gov Identifier: NCT03361371.
Collapse
Affiliation(s)
- Suzanne Schuh
- Division of Pediatric Emergency Medicine, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
- Research Institute, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Allan L. Coates
- Research Institute, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Judy Sweeney
- Research Institute, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Maggie Rumantir
- Research Institute, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Mohamed Eltorki
- Division of Pediatric Emergency Medicine, McMaster Children’s Hospital, Hamilton Health Sciences, Hamilton, Ontario, Canada
- Faculty of Health Sciences, McMaster University, Hamilton, Ontario, Canada
| | - Waleed Alqurashi
- Department of Pediatrics and Emergency Medicine, Children’s Hospital of Eastern Ontario, University of Ottawa, Ottawa, Ontario, Canada
- CHEO Research Institute, Ottawa, Ontario, Canada
| | - Amy C. Plint
- Department of Pediatrics and Emergency Medicine, Children’s Hospital of Eastern Ontario, University of Ottawa, Ottawa, Ontario, Canada
- CHEO Research Institute, Ottawa, Ontario, Canada
| | - Roger Zemek
- Department of Pediatrics and Emergency Medicine, Children’s Hospital of Eastern Ontario, University of Ottawa, Ottawa, Ontario, Canada
- CHEO Research Institute, Ottawa, Ontario, Canada
| | - Naveen Poonai
- Department of Paediatrics, Schulich School of Medicine & Dentistry, Western University, London, Ontario, Canada
- Department of Epidemiology & Biostatistics, Schulich School of Medicine & Dentistry, Western University, London, Ontario, Canada
- Children’s Health Research Institute, University of Western Ontario, London, Ontario, Canada
| | - Patricia C. Parkin
- Research Institute, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
- Division of Pediatric Medicine, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Diane Soares
- Department of Respiratory Therapy, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Rahim Moineddin
- Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
| | - Yaron Finkelstein
- Division of Pediatric Emergency Medicine, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
- Research Institute, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
- Division of Clinical Pharmacology and Toxicology, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| |
Collapse
|
6
|
Poonai N, Freedman SB, Newton AS, Sawyer S, Gaucher N, Ali S, Wright B, Miller MR, Mater A, Fitzpatrick E, Jabbour M, Zemek R, Eltorki M, Doan Q. Emergency department visits and hospital admissions for suicidal ideation, self-poisoning and self-harm among adolescents in Canada during the COVID-19 pandemic. CMAJ 2023; 195:E1221-E1230. [PMID: 37722746 PMCID: PMC10506508 DOI: 10.1503/cmaj.220507] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/16/2023] [Indexed: 09/20/2023] Open
Abstract
BACKGROUND The COVID-19 pandemic had profound effects on the mental wellbeing of adolescents. We sought to evaluate pandemic-related changes in health care use for suicidal ideation, self-poisoning and self-harm. METHODS We obtained data from the Canadian Institute for Health Information on emergency department visits and hospital admissions from April 2015 to March 2022 among adolescents aged 10-18 years in Canada. We calculated the quarterly percentage of emergency department visits and hospital admissions for a composite outcome comprising suicidal ideation, self-poisoning and self-harm relative to all-cause emergency department visits and hospital admissions. We used interrupted time-series methods to compare changes in levels and trends of these outcomes between the prepandemic (Apr. 1, 2015-Mar. 1, 2020) and pandemic (Apr. 1, 2020-Mar. 31, 2022) periods. RESULTS The average quarterly percentage of emergency department visits for suicidal ideation, self-poisoning and self-harm relative to all-cause emergency department visits was 2.30% during the prepandemic period and 3.52% during the pandemic period. The level (0.08%, 95% confidence interval [CI] -0.79% to 0.95%) or trend (0.07% per quarter, 95% CI -0.14% to 0.28%) of this percentage did not change significantly between periods. The average quarterly percentage of hospital admissions for the composite outcome relative to all-cause admissions was 7.18% during the prepandemic period and 8.96% during the pandemic period. This percentage showed no significant change in level (-0.70%, 95% CI -1.90% to 0.50%), but did show a significantly increasing trend (0.36% per quarter; 95% 0.07% to 0.65%) during the pandemic versus prepandemic periods, specifically among females aged 10-14 years (0.76% per quarter, 95% CI 0.22% to 1.30%) and females aged 15-18 years (0.56% per quarter, 95% CI 0.31% to 0.81%). INTERPRETATION The quarterly change in the percentage of hospital admissions for suicidal ideation, self-poisoning and self-harm increased among adolescent females in Canada during the first 2 years of the COVID-19 pandemic. This underscores the need to promote public health policies that mitigate the impact of the pandemic on adolescent mental health.
Collapse
Affiliation(s)
- Naveen Poonai
- Departments of Pediatrics, Internal Medicine, and Epidemiology and Biostatistics (Poonai, Miller), Schulich School of Medicine and Dentistry, Western University; Children's Health Research Institute (Poonai, Miller), London Health Sciences Centre, London, Ont.; Divisions of Pediatric Emergency Medicine and Gastroenterology (Freedman), Departments of Pediatrics and Emergency Medicine, Alberta Children's Hospital, Cumming School of Medicine, University of Calgary, Calgary, Alta.; Department of Pediatrics (Newton), Faculty of Medicine & Dentistry, College of Health Sciences, University of Alberta, Edmonton, Alta.; Department of Pediatrics (Sawyer), University of Manitoba, Winnipeg, Man.; Centre hospitalier universitaire Sainte-Justine (Gaucher), Université de Montréal, Montréal, Que.; Department of Pediatrics, and Women and Children's Health Research Institute (Ali, Wright), Faculty of Medicine & Dentistry, University of Alberta, Edmonton, Alta.; Children's Emergency Services (Mater), Department of Pediatrics, Jim Pattison Children's Hospital, Saskatoon, Sask.; IWK Health and Division of Pediatric Emergency Medicine (Fitzpatrick), Dalhousie University, Halifax, NS; Department of Pediatrics and Emergency Medicine (Jabbour, Zemek), University of Ottawa; Children's Hospital of Eastern Ontario Research Institute (Jabbour, Zemek), Ottawa, Ont.; Department of Pediatrics (Eltorki), Faculty of Health Sciences, McMaster University, Hamilton, Ont.; Department of Pediatrics (Doan), University of British Columbia, Vancouver, BC
| | - Stephen B Freedman
- Departments of Pediatrics, Internal Medicine, and Epidemiology and Biostatistics (Poonai, Miller), Schulich School of Medicine and Dentistry, Western University; Children's Health Research Institute (Poonai, Miller), London Health Sciences Centre, London, Ont.; Divisions of Pediatric Emergency Medicine and Gastroenterology (Freedman), Departments of Pediatrics and Emergency Medicine, Alberta Children's Hospital, Cumming School of Medicine, University of Calgary, Calgary, Alta.; Department of Pediatrics (Newton), Faculty of Medicine & Dentistry, College of Health Sciences, University of Alberta, Edmonton, Alta.; Department of Pediatrics (Sawyer), University of Manitoba, Winnipeg, Man.; Centre hospitalier universitaire Sainte-Justine (Gaucher), Université de Montréal, Montréal, Que.; Department of Pediatrics, and Women and Children's Health Research Institute (Ali, Wright), Faculty of Medicine & Dentistry, University of Alberta, Edmonton, Alta.; Children's Emergency Services (Mater), Department of Pediatrics, Jim Pattison Children's Hospital, Saskatoon, Sask.; IWK Health and Division of Pediatric Emergency Medicine (Fitzpatrick), Dalhousie University, Halifax, NS; Department of Pediatrics and Emergency Medicine (Jabbour, Zemek), University of Ottawa; Children's Hospital of Eastern Ontario Research Institute (Jabbour, Zemek), Ottawa, Ont.; Department of Pediatrics (Eltorki), Faculty of Health Sciences, McMaster University, Hamilton, Ont.; Department of Pediatrics (Doan), University of British Columbia, Vancouver, BC
| | - Amanda S Newton
- Departments of Pediatrics, Internal Medicine, and Epidemiology and Biostatistics (Poonai, Miller), Schulich School of Medicine and Dentistry, Western University; Children's Health Research Institute (Poonai, Miller), London Health Sciences Centre, London, Ont.; Divisions of Pediatric Emergency Medicine and Gastroenterology (Freedman), Departments of Pediatrics and Emergency Medicine, Alberta Children's Hospital, Cumming School of Medicine, University of Calgary, Calgary, Alta.; Department of Pediatrics (Newton), Faculty of Medicine & Dentistry, College of Health Sciences, University of Alberta, Edmonton, Alta.; Department of Pediatrics (Sawyer), University of Manitoba, Winnipeg, Man.; Centre hospitalier universitaire Sainte-Justine (Gaucher), Université de Montréal, Montréal, Que.; Department of Pediatrics, and Women and Children's Health Research Institute (Ali, Wright), Faculty of Medicine & Dentistry, University of Alberta, Edmonton, Alta.; Children's Emergency Services (Mater), Department of Pediatrics, Jim Pattison Children's Hospital, Saskatoon, Sask.; IWK Health and Division of Pediatric Emergency Medicine (Fitzpatrick), Dalhousie University, Halifax, NS; Department of Pediatrics and Emergency Medicine (Jabbour, Zemek), University of Ottawa; Children's Hospital of Eastern Ontario Research Institute (Jabbour, Zemek), Ottawa, Ont.; Department of Pediatrics (Eltorki), Faculty of Health Sciences, McMaster University, Hamilton, Ont.; Department of Pediatrics (Doan), University of British Columbia, Vancouver, BC
| | - Scott Sawyer
- Departments of Pediatrics, Internal Medicine, and Epidemiology and Biostatistics (Poonai, Miller), Schulich School of Medicine and Dentistry, Western University; Children's Health Research Institute (Poonai, Miller), London Health Sciences Centre, London, Ont.; Divisions of Pediatric Emergency Medicine and Gastroenterology (Freedman), Departments of Pediatrics and Emergency Medicine, Alberta Children's Hospital, Cumming School of Medicine, University of Calgary, Calgary, Alta.; Department of Pediatrics (Newton), Faculty of Medicine & Dentistry, College of Health Sciences, University of Alberta, Edmonton, Alta.; Department of Pediatrics (Sawyer), University of Manitoba, Winnipeg, Man.; Centre hospitalier universitaire Sainte-Justine (Gaucher), Université de Montréal, Montréal, Que.; Department of Pediatrics, and Women and Children's Health Research Institute (Ali, Wright), Faculty of Medicine & Dentistry, University of Alberta, Edmonton, Alta.; Children's Emergency Services (Mater), Department of Pediatrics, Jim Pattison Children's Hospital, Saskatoon, Sask.; IWK Health and Division of Pediatric Emergency Medicine (Fitzpatrick), Dalhousie University, Halifax, NS; Department of Pediatrics and Emergency Medicine (Jabbour, Zemek), University of Ottawa; Children's Hospital of Eastern Ontario Research Institute (Jabbour, Zemek), Ottawa, Ont.; Department of Pediatrics (Eltorki), Faculty of Health Sciences, McMaster University, Hamilton, Ont.; Department of Pediatrics (Doan), University of British Columbia, Vancouver, BC
| | - Nathalie Gaucher
- Departments of Pediatrics, Internal Medicine, and Epidemiology and Biostatistics (Poonai, Miller), Schulich School of Medicine and Dentistry, Western University; Children's Health Research Institute (Poonai, Miller), London Health Sciences Centre, London, Ont.; Divisions of Pediatric Emergency Medicine and Gastroenterology (Freedman), Departments of Pediatrics and Emergency Medicine, Alberta Children's Hospital, Cumming School of Medicine, University of Calgary, Calgary, Alta.; Department of Pediatrics (Newton), Faculty of Medicine & Dentistry, College of Health Sciences, University of Alberta, Edmonton, Alta.; Department of Pediatrics (Sawyer), University of Manitoba, Winnipeg, Man.; Centre hospitalier universitaire Sainte-Justine (Gaucher), Université de Montréal, Montréal, Que.; Department of Pediatrics, and Women and Children's Health Research Institute (Ali, Wright), Faculty of Medicine & Dentistry, University of Alberta, Edmonton, Alta.; Children's Emergency Services (Mater), Department of Pediatrics, Jim Pattison Children's Hospital, Saskatoon, Sask.; IWK Health and Division of Pediatric Emergency Medicine (Fitzpatrick), Dalhousie University, Halifax, NS; Department of Pediatrics and Emergency Medicine (Jabbour, Zemek), University of Ottawa; Children's Hospital of Eastern Ontario Research Institute (Jabbour, Zemek), Ottawa, Ont.; Department of Pediatrics (Eltorki), Faculty of Health Sciences, McMaster University, Hamilton, Ont.; Department of Pediatrics (Doan), University of British Columbia, Vancouver, BC
| | - Samina Ali
- Departments of Pediatrics, Internal Medicine, and Epidemiology and Biostatistics (Poonai, Miller), Schulich School of Medicine and Dentistry, Western University; Children's Health Research Institute (Poonai, Miller), London Health Sciences Centre, London, Ont.; Divisions of Pediatric Emergency Medicine and Gastroenterology (Freedman), Departments of Pediatrics and Emergency Medicine, Alberta Children's Hospital, Cumming School of Medicine, University of Calgary, Calgary, Alta.; Department of Pediatrics (Newton), Faculty of Medicine & Dentistry, College of Health Sciences, University of Alberta, Edmonton, Alta.; Department of Pediatrics (Sawyer), University of Manitoba, Winnipeg, Man.; Centre hospitalier universitaire Sainte-Justine (Gaucher), Université de Montréal, Montréal, Que.; Department of Pediatrics, and Women and Children's Health Research Institute (Ali, Wright), Faculty of Medicine & Dentistry, University of Alberta, Edmonton, Alta.; Children's Emergency Services (Mater), Department of Pediatrics, Jim Pattison Children's Hospital, Saskatoon, Sask.; IWK Health and Division of Pediatric Emergency Medicine (Fitzpatrick), Dalhousie University, Halifax, NS; Department of Pediatrics and Emergency Medicine (Jabbour, Zemek), University of Ottawa; Children's Hospital of Eastern Ontario Research Institute (Jabbour, Zemek), Ottawa, Ont.; Department of Pediatrics (Eltorki), Faculty of Health Sciences, McMaster University, Hamilton, Ont.; Department of Pediatrics (Doan), University of British Columbia, Vancouver, BC
| | - Bruce Wright
- Departments of Pediatrics, Internal Medicine, and Epidemiology and Biostatistics (Poonai, Miller), Schulich School of Medicine and Dentistry, Western University; Children's Health Research Institute (Poonai, Miller), London Health Sciences Centre, London, Ont.; Divisions of Pediatric Emergency Medicine and Gastroenterology (Freedman), Departments of Pediatrics and Emergency Medicine, Alberta Children's Hospital, Cumming School of Medicine, University of Calgary, Calgary, Alta.; Department of Pediatrics (Newton), Faculty of Medicine & Dentistry, College of Health Sciences, University of Alberta, Edmonton, Alta.; Department of Pediatrics (Sawyer), University of Manitoba, Winnipeg, Man.; Centre hospitalier universitaire Sainte-Justine (Gaucher), Université de Montréal, Montréal, Que.; Department of Pediatrics, and Women and Children's Health Research Institute (Ali, Wright), Faculty of Medicine & Dentistry, University of Alberta, Edmonton, Alta.; Children's Emergency Services (Mater), Department of Pediatrics, Jim Pattison Children's Hospital, Saskatoon, Sask.; IWK Health and Division of Pediatric Emergency Medicine (Fitzpatrick), Dalhousie University, Halifax, NS; Department of Pediatrics and Emergency Medicine (Jabbour, Zemek), University of Ottawa; Children's Hospital of Eastern Ontario Research Institute (Jabbour, Zemek), Ottawa, Ont.; Department of Pediatrics (Eltorki), Faculty of Health Sciences, McMaster University, Hamilton, Ont.; Department of Pediatrics (Doan), University of British Columbia, Vancouver, BC
| | - Michael R Miller
- Departments of Pediatrics, Internal Medicine, and Epidemiology and Biostatistics (Poonai, Miller), Schulich School of Medicine and Dentistry, Western University; Children's Health Research Institute (Poonai, Miller), London Health Sciences Centre, London, Ont.; Divisions of Pediatric Emergency Medicine and Gastroenterology (Freedman), Departments of Pediatrics and Emergency Medicine, Alberta Children's Hospital, Cumming School of Medicine, University of Calgary, Calgary, Alta.; Department of Pediatrics (Newton), Faculty of Medicine & Dentistry, College of Health Sciences, University of Alberta, Edmonton, Alta.; Department of Pediatrics (Sawyer), University of Manitoba, Winnipeg, Man.; Centre hospitalier universitaire Sainte-Justine (Gaucher), Université de Montréal, Montréal, Que.; Department of Pediatrics, and Women and Children's Health Research Institute (Ali, Wright), Faculty of Medicine & Dentistry, University of Alberta, Edmonton, Alta.; Children's Emergency Services (Mater), Department of Pediatrics, Jim Pattison Children's Hospital, Saskatoon, Sask.; IWK Health and Division of Pediatric Emergency Medicine (Fitzpatrick), Dalhousie University, Halifax, NS; Department of Pediatrics and Emergency Medicine (Jabbour, Zemek), University of Ottawa; Children's Hospital of Eastern Ontario Research Institute (Jabbour, Zemek), Ottawa, Ont.; Department of Pediatrics (Eltorki), Faculty of Health Sciences, McMaster University, Hamilton, Ont.; Department of Pediatrics (Doan), University of British Columbia, Vancouver, BC
| | - Ahmed Mater
- Departments of Pediatrics, Internal Medicine, and Epidemiology and Biostatistics (Poonai, Miller), Schulich School of Medicine and Dentistry, Western University; Children's Health Research Institute (Poonai, Miller), London Health Sciences Centre, London, Ont.; Divisions of Pediatric Emergency Medicine and Gastroenterology (Freedman), Departments of Pediatrics and Emergency Medicine, Alberta Children's Hospital, Cumming School of Medicine, University of Calgary, Calgary, Alta.; Department of Pediatrics (Newton), Faculty of Medicine & Dentistry, College of Health Sciences, University of Alberta, Edmonton, Alta.; Department of Pediatrics (Sawyer), University of Manitoba, Winnipeg, Man.; Centre hospitalier universitaire Sainte-Justine (Gaucher), Université de Montréal, Montréal, Que.; Department of Pediatrics, and Women and Children's Health Research Institute (Ali, Wright), Faculty of Medicine & Dentistry, University of Alberta, Edmonton, Alta.; Children's Emergency Services (Mater), Department of Pediatrics, Jim Pattison Children's Hospital, Saskatoon, Sask.; IWK Health and Division of Pediatric Emergency Medicine (Fitzpatrick), Dalhousie University, Halifax, NS; Department of Pediatrics and Emergency Medicine (Jabbour, Zemek), University of Ottawa; Children's Hospital of Eastern Ontario Research Institute (Jabbour, Zemek), Ottawa, Ont.; Department of Pediatrics (Eltorki), Faculty of Health Sciences, McMaster University, Hamilton, Ont.; Department of Pediatrics (Doan), University of British Columbia, Vancouver, BC
| | - Eleanor Fitzpatrick
- Departments of Pediatrics, Internal Medicine, and Epidemiology and Biostatistics (Poonai, Miller), Schulich School of Medicine and Dentistry, Western University; Children's Health Research Institute (Poonai, Miller), London Health Sciences Centre, London, Ont.; Divisions of Pediatric Emergency Medicine and Gastroenterology (Freedman), Departments of Pediatrics and Emergency Medicine, Alberta Children's Hospital, Cumming School of Medicine, University of Calgary, Calgary, Alta.; Department of Pediatrics (Newton), Faculty of Medicine & Dentistry, College of Health Sciences, University of Alberta, Edmonton, Alta.; Department of Pediatrics (Sawyer), University of Manitoba, Winnipeg, Man.; Centre hospitalier universitaire Sainte-Justine (Gaucher), Université de Montréal, Montréal, Que.; Department of Pediatrics, and Women and Children's Health Research Institute (Ali, Wright), Faculty of Medicine & Dentistry, University of Alberta, Edmonton, Alta.; Children's Emergency Services (Mater), Department of Pediatrics, Jim Pattison Children's Hospital, Saskatoon, Sask.; IWK Health and Division of Pediatric Emergency Medicine (Fitzpatrick), Dalhousie University, Halifax, NS; Department of Pediatrics and Emergency Medicine (Jabbour, Zemek), University of Ottawa; Children's Hospital of Eastern Ontario Research Institute (Jabbour, Zemek), Ottawa, Ont.; Department of Pediatrics (Eltorki), Faculty of Health Sciences, McMaster University, Hamilton, Ont.; Department of Pediatrics (Doan), University of British Columbia, Vancouver, BC
| | - Mona Jabbour
- Departments of Pediatrics, Internal Medicine, and Epidemiology and Biostatistics (Poonai, Miller), Schulich School of Medicine and Dentistry, Western University; Children's Health Research Institute (Poonai, Miller), London Health Sciences Centre, London, Ont.; Divisions of Pediatric Emergency Medicine and Gastroenterology (Freedman), Departments of Pediatrics and Emergency Medicine, Alberta Children's Hospital, Cumming School of Medicine, University of Calgary, Calgary, Alta.; Department of Pediatrics (Newton), Faculty of Medicine & Dentistry, College of Health Sciences, University of Alberta, Edmonton, Alta.; Department of Pediatrics (Sawyer), University of Manitoba, Winnipeg, Man.; Centre hospitalier universitaire Sainte-Justine (Gaucher), Université de Montréal, Montréal, Que.; Department of Pediatrics, and Women and Children's Health Research Institute (Ali, Wright), Faculty of Medicine & Dentistry, University of Alberta, Edmonton, Alta.; Children's Emergency Services (Mater), Department of Pediatrics, Jim Pattison Children's Hospital, Saskatoon, Sask.; IWK Health and Division of Pediatric Emergency Medicine (Fitzpatrick), Dalhousie University, Halifax, NS; Department of Pediatrics and Emergency Medicine (Jabbour, Zemek), University of Ottawa; Children's Hospital of Eastern Ontario Research Institute (Jabbour, Zemek), Ottawa, Ont.; Department of Pediatrics (Eltorki), Faculty of Health Sciences, McMaster University, Hamilton, Ont.; Department of Pediatrics (Doan), University of British Columbia, Vancouver, BC
| | - Roger Zemek
- Departments of Pediatrics, Internal Medicine, and Epidemiology and Biostatistics (Poonai, Miller), Schulich School of Medicine and Dentistry, Western University; Children's Health Research Institute (Poonai, Miller), London Health Sciences Centre, London, Ont.; Divisions of Pediatric Emergency Medicine and Gastroenterology (Freedman), Departments of Pediatrics and Emergency Medicine, Alberta Children's Hospital, Cumming School of Medicine, University of Calgary, Calgary, Alta.; Department of Pediatrics (Newton), Faculty of Medicine & Dentistry, College of Health Sciences, University of Alberta, Edmonton, Alta.; Department of Pediatrics (Sawyer), University of Manitoba, Winnipeg, Man.; Centre hospitalier universitaire Sainte-Justine (Gaucher), Université de Montréal, Montréal, Que.; Department of Pediatrics, and Women and Children's Health Research Institute (Ali, Wright), Faculty of Medicine & Dentistry, University of Alberta, Edmonton, Alta.; Children's Emergency Services (Mater), Department of Pediatrics, Jim Pattison Children's Hospital, Saskatoon, Sask.; IWK Health and Division of Pediatric Emergency Medicine (Fitzpatrick), Dalhousie University, Halifax, NS; Department of Pediatrics and Emergency Medicine (Jabbour, Zemek), University of Ottawa; Children's Hospital of Eastern Ontario Research Institute (Jabbour, Zemek), Ottawa, Ont.; Department of Pediatrics (Eltorki), Faculty of Health Sciences, McMaster University, Hamilton, Ont.; Department of Pediatrics (Doan), University of British Columbia, Vancouver, BC
| | - Mohamed Eltorki
- Departments of Pediatrics, Internal Medicine, and Epidemiology and Biostatistics (Poonai, Miller), Schulich School of Medicine and Dentistry, Western University; Children's Health Research Institute (Poonai, Miller), London Health Sciences Centre, London, Ont.; Divisions of Pediatric Emergency Medicine and Gastroenterology (Freedman), Departments of Pediatrics and Emergency Medicine, Alberta Children's Hospital, Cumming School of Medicine, University of Calgary, Calgary, Alta.; Department of Pediatrics (Newton), Faculty of Medicine & Dentistry, College of Health Sciences, University of Alberta, Edmonton, Alta.; Department of Pediatrics (Sawyer), University of Manitoba, Winnipeg, Man.; Centre hospitalier universitaire Sainte-Justine (Gaucher), Université de Montréal, Montréal, Que.; Department of Pediatrics, and Women and Children's Health Research Institute (Ali, Wright), Faculty of Medicine & Dentistry, University of Alberta, Edmonton, Alta.; Children's Emergency Services (Mater), Department of Pediatrics, Jim Pattison Children's Hospital, Saskatoon, Sask.; IWK Health and Division of Pediatric Emergency Medicine (Fitzpatrick), Dalhousie University, Halifax, NS; Department of Pediatrics and Emergency Medicine (Jabbour, Zemek), University of Ottawa; Children's Hospital of Eastern Ontario Research Institute (Jabbour, Zemek), Ottawa, Ont.; Department of Pediatrics (Eltorki), Faculty of Health Sciences, McMaster University, Hamilton, Ont.; Department of Pediatrics (Doan), University of British Columbia, Vancouver, BC
| | - Quynh Doan
- Departments of Pediatrics, Internal Medicine, and Epidemiology and Biostatistics (Poonai, Miller), Schulich School of Medicine and Dentistry, Western University; Children's Health Research Institute (Poonai, Miller), London Health Sciences Centre, London, Ont.; Divisions of Pediatric Emergency Medicine and Gastroenterology (Freedman), Departments of Pediatrics and Emergency Medicine, Alberta Children's Hospital, Cumming School of Medicine, University of Calgary, Calgary, Alta.; Department of Pediatrics (Newton), Faculty of Medicine & Dentistry, College of Health Sciences, University of Alberta, Edmonton, Alta.; Department of Pediatrics (Sawyer), University of Manitoba, Winnipeg, Man.; Centre hospitalier universitaire Sainte-Justine (Gaucher), Université de Montréal, Montréal, Que.; Department of Pediatrics, and Women and Children's Health Research Institute (Ali, Wright), Faculty of Medicine & Dentistry, University of Alberta, Edmonton, Alta.; Children's Emergency Services (Mater), Department of Pediatrics, Jim Pattison Children's Hospital, Saskatoon, Sask.; IWK Health and Division of Pediatric Emergency Medicine (Fitzpatrick), Dalhousie University, Halifax, NS; Department of Pediatrics and Emergency Medicine (Jabbour, Zemek), University of Ottawa; Children's Hospital of Eastern Ontario Research Institute (Jabbour, Zemek), Ottawa, Ont.; Department of Pediatrics (Eltorki), Faculty of Health Sciences, McMaster University, Hamilton, Ont.; Department of Pediatrics (Doan), University of British Columbia, Vancouver, BC
| |
Collapse
|
7
|
Ramgopal S, Rodean J, Alpern ER, Hall M, Chaudhari PP, Marin JR, Shah SS, Freedman SB, Eltorki M, Badaki-Makun O, Shapiro DJ, Rhine T, Morse RB, Neuman MI. Ambulatory follow-up among publicly insured children discharged from the emergency department. Acad Emerg Med 2023; 30:721-730. [PMID: 36809681 DOI: 10.1111/acem.14704] [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: 10/20/2022] [Revised: 02/13/2023] [Accepted: 02/17/2023] [Indexed: 02/24/2023]
Abstract
BACKGROUND While children discharged from the emergency department (ED) are frequently advised to follow up with ambulatory care providers, the extent to which this occurs is unknown. We sought to characterize the proportion of publicly insured children who have an ambulatory visit following ED discharge, identify factors associated with ambulatory follow-up, and evaluate the association of ambulatory follow-up with subsequent hospital-based health care utilization. METHODS We performed a cross-sectional study of pediatric (<18 years) encounters during 2019 included in the IBM Watson Medicaid MarketScan claims database from seven U.S. states. Our primary outcome was an ambulatory follow-up visit within 7 days of ED discharge. Secondary outcomes were 7-day ED return visits and hospitalizations. Logistic regression and Cox proportional hazards were used for multivariable modeling. RESULTS We included 1,408,406 index ED encounters (median age 5 years, IQR 2-10 years), for which a 7-day ambulatory visit occurred in 280,602 (19.9%). Conditions with the highest proportion of 7-day ambulatory follow-up included seizures (36.4%); allergic, immunologic, and rheumatologic diseases (24.6%); other gastrointestinal diseases (24.5%); and fever (24.1%). Ambulatory follow-up was associated with younger age, Hispanic ethnicity, weekend ED discharge, ambulatory encounters prior to the ED visit, and diagnostic testing performed during the ED encounter. Ambulatory follow-up was inversely associated with Black race and ambulatory care-sensitive or complex chronic conditions. In Cox models, ambulatory follow-up was associated with a higher hazard ratio (HR) of subsequent ED return (HR range 1.32-1.65) visit and hospitalization (HR range 3.10-4.03). CONCLUSIONS One-fifth of children discharged from the ED have an ambulatory visit within 7 days, which varied by patient characteristics and diagnoses. Children with ambulatory follow-up have a greater subsequent health care utilization, including subsequent ED visit and/or hospitalization. These findings identify the need to further research the role and costs associated with routine post-ED visit follow-up.
Collapse
Affiliation(s)
- Sriram Ramgopal
- Division of Emergency Medicine, Department of Pediatrics, Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | | | - Elizabeth R Alpern
- Division of Emergency Medicine, Department of Pediatrics, Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Matt Hall
- Children's Hospital Association, Lenexa, Kansas, USA
| | - Pradip P Chaudhari
- Division of Emergency and Transport Medicine, Children's Hospital Los Angeles, Department of Pediatrics, Keck School of Medicine of the University of Southern California, Los Angeles, California, USA
| | - Jennifer R Marin
- Department of Pediatrics, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
- Department of Emergency Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Samir S Shah
- Division of Hospital Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
| | - Stephen B Freedman
- Sections of Pediatric Emergency Medicine and Gastroenterology, Departments of Pediatrics and Emergency Medicine, Alberta Children's Hospital, Alberta Children's Hospital Research Institute, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Mohamed Eltorki
- Division of Pediatric Emergency Medicine, Department of Pediatrics, McMaster Children's Hospital, McMaster University, Hamilton, Ontario, Canada
| | - Oluwakemi Badaki-Makun
- Division of Pediatric Emergency Medicine, Department of Pediatrics, Johns Hopkins University School of Medicine, Center for Data Science in Emergency Medicine, Johns Hopkins University, Baltimore, Maryland, USA
| | - Daniel J Shapiro
- Division of Emergency Medicine, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Tara Rhine
- Division of Emergency Medicine, Department of Pediatrics, Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
| | - Rustin B Morse
- Department of Pediatrics, Center for Clinical Excellence, Nationwide Children's Hospital, The Ohio State University College of Medicine, Ohio, Columbus, USA
| | - Mark I Neuman
- Division of Emergency Medicine, Boston Children's Hospital, Boston, Massachusetts, USA
| |
Collapse
|
8
|
Rezk E, Eltorki M, El-Dakhakhni W. Interpretable Skin Cancer Classification based on Incremental Domain Knowledge Learning. J Healthc Inform Res 2023; 7:59-83. [PMID: 36910915 PMCID: PMC9995827 DOI: 10.1007/s41666-023-00127-4] [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] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2022] [Revised: 01/02/2023] [Accepted: 02/03/2023] [Indexed: 02/17/2023]
Abstract
The recent advances in artificial intelligence have led to the rapid development of computer-aided skin cancer diagnosis applications that perform on par with dermatologists. However, the black-box nature of such applications makes it difficult for physicians to trust the predicted decisions, subsequently preventing the proliferation of such applications in the clinical workflow. In this work, we aim to address this challenge by developing an interpretable skin cancer diagnosis approach using clinical images. Accordingly, a skin cancer diagnosis model consolidated with two interpretability methods is developed. The first interpretability method integrates skin cancer diagnosis domain knowledge, characterized by a skin lesion taxonomy, into model development, whereas the other method focuses on visualizing the decision-making process by highlighting the dominant of interest regions of skin lesion images. The proposed model is trained and validated on clinical images since the latter are easily obtainable by non-specialist healthcare providers. The results demonstrate the effectiveness of incorporating lesion taxonomy in improving model classification accuracy, where our model can predict the skin lesion origin as melanocytic or non-melanocytic with an accuracy of 87%, predict lesion malignancy with 77% accuracy, and provide disease diagnosis with an accuracy of 71%. In addition, the implemented interpretability methods assist understand the model's decision-making process and detecting misdiagnoses. This work is a step toward achieving interpretability in skin cancer diagnosis using clinical images. The developed approach can assist general practitioners to make an early diagnosis, thus reducing the redundant referrals that expert dermatologists receive for further investigations.
Collapse
Affiliation(s)
- Eman Rezk
- School of Computational Science and Engineering, McMaster University, Hamilton, ON Canada
| | - Mohamed Eltorki
- Faculty of Health Sciences, McMaster University, Hamilton, ON Canada
| | - Wael El-Dakhakhni
- School of Computational Science and Engineering, McMaster University, Hamilton, ON Canada
| |
Collapse
|
9
|
MacBain E, Eltorki M, Marjerrison S, Pardhan A, Wahi G, Ngo QN. Prevalence and characterization of food insecurity in a Canadian paediatric emergency department. Paediatr Child Health 2023. [DOI: 10.1093/pch/pxac133] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/19/2023] Open
Abstract
Abstract
Objectives
Food insecurity (FI) is associated with a number of adverse child health outcomes and increased emergency department (ED) use. The COVID-19 pandemic exacerbated the financial hardship faced by many families. We sought to determine the prevalence of FI among children with ED visits, compare this to pre-pandemic rates, and describe associated risk factors.
Methods
From September to December 2021, families presenting to a Canadian paediatric ED were asked to complete a survey screening for FI along with health and demographic information. Results were compared to data collected in 2012. Multivariable logistic regression was used to measure associations with FI.
Results
In 2021, 26% (n = 173/665) of families identified as food insecure compared to 22.7% in 2012 (n = 146/644) a difference of 3.3% (95% CI [−1.4%, 8.1%]). In multivariable analysis, greater number of children in the home (OR 1.19, 95% CI [1.01, 1.41]), financial strain from medical expenses (OR 5.31, 95% CI [3.45, 8.18]), and a lack of primary care access (OR 1.27, 95% CI [1.08, 1.51]) were independent predictors of FI. Less than half of families with FI reported use of food charity, most commonly food banks, while one-quarter received help from family or friends. Families experiencing FI expressed a preference for support through free or low-cost meals and financial assistance with medical expenses.
Conclusion
More than one in four families attending a paediatric ED screened positive for FI. Future research is needed to examine the effect of support interventions for families assessed in medical care facilities including financial support for those with chronic medical conditions.
Collapse
Affiliation(s)
- Elspeth MacBain
- Department of Pediatrics, McMaster University , Hamilton, ON , Canada
- McMaster Children’s Hospital , Hamilton, ON , Canada
| | - Mohamed Eltorki
- Department of Pediatrics, McMaster University , Hamilton, ON , Canada
- McMaster Children’s Hospital , Hamilton, ON , Canada
| | - Stacey Marjerrison
- Department of Pediatrics, McMaster University , Hamilton, ON , Canada
- McMaster Children’s Hospital , Hamilton, ON , Canada
| | - Alim Pardhan
- Department of Pediatrics, McMaster University , Hamilton, ON , Canada
- McMaster Children’s Hospital , Hamilton, ON , Canada
| | - Gita Wahi
- Department of Pediatrics, McMaster University , Hamilton, ON , Canada
- McMaster Children’s Hospital , Hamilton, ON , Canada
| | - Quang N Ngo
- Department of Pediatrics, McMaster University , Hamilton, ON , Canada
- McMaster Children’s Hospital , Hamilton, ON , Canada
| |
Collapse
|
10
|
Meckler GD, Alqurashi W, Eltorki M, Curtis SJ, Doyle E, Kam AJ, Lim R, MacPhee S, Schuh S, Wright B, Johnson DW. Epinephrine metered-dose inhaler for pediatric croup. Acad Emerg Med 2023; 30:144-146. [PMID: 36307996 DOI: 10.1111/acem.14616] [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] [Subscribe] [Scholar Register] [Received: 08/10/2022] [Revised: 10/12/2022] [Accepted: 10/24/2022] [Indexed: 11/29/2022]
Affiliation(s)
- Garth D Meckler
- Departments of Pediatrics and Emergency Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | - Waleed Alqurashi
- Department of Pediatrics and Emergency Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Mohamed Eltorki
- Division of Pediatric Emergency Medicine, Department of Pediatrics, McMaster University, Hamilton, Ontario, Canada
| | - Sarah J Curtis
- Departments of Pediatrics and Emergency Medicine, University of Alberta, Women's and Children's Health Research Institute, Alberta, Canada
| | - Elisabete Doyle
- Department of Pediatric Emergency Medicine, Max Rady School of Medicine, University of Manitoba, Winnipeg, Manitoba, Canada
| | - April J Kam
- Division of Pediatric Emergency Medicine, Department of Pediatrics, McMaster University, Hamilton, Ontario, Canada
| | - Rodrick Lim
- Department of Pediatrics and Medicine, Schulich School of Medicine & Dentistry, Western University, London, Ontario, Canada
| | - Shannon MacPhee
- Department of Emergency Medicine, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Suzanne Schuh
- Division of Pediatric Emergency Medicine, Department of Pediatrics, The Hospital for SickKids Research Institute, University of Toronto, Toronto, Ontario, Canada
| | - Bruce Wright
- Departments of Pediatrics and Emergency Medicine, University of Alberta, Women's and Children's Health Research Institute, Alberta, Canada
| | - David W Johnson
- Departments of Pediatrics, Emergency Medicine, and Physiology & Pharmacology, Cumming School of Medicine, Alberta Children's Hospital Research Institute, University of Calgary, Calgary, Onbtario, Canada
| |
Collapse
|
11
|
Pernica JM, Kam AJ, Eltorki M, Khan S, Goldfarb DM, Smaill F, Wong J, Ewusie J, Smieja M, Sung M, Mertz D, Thabane L, Loeb M. Novel care pathway to optimise antimicrobial prescribing for uncomplicated community-acquired pneumonia: study protocol for a prospective before-after cohort study in the emergency department of a tertiary care Canadian children's hospital. BMJ Open 2022; 12:e062360. [PMID: 36396301 PMCID: PMC9677018 DOI: 10.1136/bmjopen-2022-062360] [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] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
INTRODUCTION Evidence-based recommendations for paediatric community-acquired pneumonia (CAP) diagnosis and management are needed. Uncomplicated CAP is often caused by respiratory viruses, especially in younger children; these episodes self-resolve without antibiotic treatment. Unfortunately, there are no clinical criteria that reliably discriminate between viral and bacterial disease, and so the majority of children diagnosed with CAP are given antibiotics-even though these will often not help and may cause harm. We have developed a novel care pathway that incorporates point-of-care biomarkers, radiographic patterns, microbiological testing and targeted follow-up. The primary study objective is to determine if the care pathway will be associated with less antimicrobial prescribing. METHODS AND ANALYSIS A prospective, before-after, study. Previously well children aged≥6 months presenting to a paediatric emergency department (ED) that have at least one respiratory symptom/sign, receive chest radiography, and are diagnosed with CAP by the ED physician will be eligible. Those with medical comorbidities, recently diagnosed pulmonary infection, or ongoing fever after≥4 days of antimicrobial therapy will be excluded. In the control (before) phase, eligible participants will be managed as per the standard of care. In the intervention (after) phase, eligible participants will be managed as per the novel care pathway. The primary outcome will be the proportion of participants in each phase who receive antimicrobial treatment for CAP. The secondary outcomes include: clinical cure; re-presentation to the ED; hospitalisation; time to resolution of symptoms; drug adverse events; caregiver satisfaction; child absenteeism from daycare/school; and caregiver absenteeism from work. ETHICS AND DISSEMINATION All study documentation has been approved by the Hamilton Integrated Research Ethics Board and informed consent will be obtained from all participants. Data from this study will be presented at major conferences and published in peer-reviewed publications to facilitate collaborations with networks of clinicians experienced in the dissemination of clinical guidelines. TRIAL REGISTRATION NUMBER NCT05114161.
Collapse
Affiliation(s)
- Jeffrey M Pernica
- Department of Pediatrics, McMaster University Faculty of Health Sciences, Hamilton, Ontario, Canada
- Department of Health Research Methods, Evidence, and Impact, McMaster University Faculty of Health Sciences, Hamilton, Ontario, Canada
| | - April J Kam
- Department of Pediatrics, McMaster University Faculty of Health Sciences, Hamilton, Ontario, Canada
| | - Mohamed Eltorki
- Department of Pediatrics, McMaster University Faculty of Health Sciences, Hamilton, Ontario, Canada
| | - Sarah Khan
- Department of Pediatrics, McMaster University Faculty of Health Sciences, Hamilton, Ontario, Canada
| | - David M Goldfarb
- Department of Pathology and Laboratory Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | - Fiona Smaill
- Department of Pathology and Molecular Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Jacqueline Wong
- Department of Pediatrics, McMaster University Faculty of Health Sciences, Hamilton, Ontario, Canada
| | - Joycelyne Ewusie
- Department of Health Research Methods, Evidence, and Impact, McMaster University Faculty of Health Sciences, Hamilton, Ontario, Canada
| | - Marek Smieja
- Department of Health Research Methods, Evidence, and Impact, McMaster University Faculty of Health Sciences, Hamilton, Ontario, Canada
- Department of Pathology and Molecular Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Melani Sung
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Dominik Mertz
- Department of Health Research Methods, Evidence, and Impact, McMaster University Faculty of Health Sciences, Hamilton, Ontario, Canada
- Department of Pathology and Molecular Medicine, McMaster University, Hamilton, Ontario, Canada
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Lehana Thabane
- Department of Health Research Methods, Evidence, and Impact, McMaster University Faculty of Health Sciences, Hamilton, Ontario, Canada
| | - Mark Loeb
- Department of Health Research Methods, Evidence, and Impact, McMaster University Faculty of Health Sciences, Hamilton, Ontario, Canada
- Department of Pathology and Molecular Medicine, McMaster University, Hamilton, Ontario, Canada
| |
Collapse
|
12
|
Alqurashi W, Shaker M, Wells GA, Collins GS, Greenhawt M, Curran JA, Zemek R, Schuh S, Ellis A, Gerdts J, Kreviazuk C, Dixon A, Eltorki M, Freedman SB, Gravel J, Poonai N, Worm M, Plint AC. Canadian Anaphylaxis Network-Predicting Recurrence after Emergency Presentation for Allergic REaction (CAN-PREPARE): a prospective, cohort study protocol. BMJ Open 2022; 12:e061976. [PMID: 36316072 PMCID: PMC9628530 DOI: 10.1136/bmjopen-2022-061976] [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] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
INTRODUCTION Anaphylaxis is a severe, potentially fatal multiorgan system manifestation of an allergic reaction. The highest incidence of anaphylaxis is in children and adolescents. Biphasic anaphylaxis (BA) is defined as the recurrence of allergic symptoms after resolution of an initial reaction. It has been reported to occur in 10%-20% of cases within 1-48 hours from the onset of the initial reaction. The dilemma for physicians is determining which patients with resolved anaphylaxis should be observed for BA and for how long. Guidelines for duration of postanaphylaxis monitoring vary, are based on limited evidence and can have unintended negative impacts on patient safety, quality of life and healthcare resources. The objectives of this study are to derive a prognostic model for BA and to develop a risk-scoring system that informs disposition decisions of children who present to emergency departments (ED) with anaphylaxis. METHODS AND ANALYSIS This prospective multicentre cohort study will enrol 1682 patients from seven paediatric EDs that are members of the Paediatric Emergency Research Canada network. We will enrol patients younger than 18 years of age with an allergic reaction meeting anaphylaxis diagnostic criteria. Trained ED research assistants will screen, obtain consent and prospectively collect study data. Research assistants will follow patients during their ED visit and ascertain, in conjunction with the medical team, if the patient develops BA. A standardised follow-up survey conducted following study enrolment will determine if a biphasic reaction occurred after ED disposition. Model development will conform to the broad principles of the PROGRESS (Prognosis Research Strategy) framework and reporting will follow the Transparent Reporting of a multivariable prediction model for Individual Prognosis or Diagnosis Statement. ETHICS AND DISSEMINATION Ethics approval has been received from all participating centres. Our dissemination plan focuses on informing clinicians, policy makers and parents of the results through publication in peer-reviewed journals and broadcasting on multiple media platforms. TRIAL REGISTRATION NUMBER NCT05135377.
Collapse
Affiliation(s)
- Waleed Alqurashi
- Department of Pediatrics and Emergency Medicine, University of Ottawa Faculty of Medicine, Ottawa, Ontario, Canada
- Children's Hospital of Eastern Ontario Research Institute, Ottawa, Ontario, Canada
| | - Marcus Shaker
- Section of Allergy and Clinical Immunology, Children's Hospital at Dartmouth-Hitchcock, Lebanon, New Hampshire, USA
| | - George A Wells
- Cardiovascular Research Methods Centre, University of Ottawa Heart Institute, Ottawa, Ontario, Canada
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, Ontario, Canada
| | - Gary Stephen Collins
- Centre for Statistics in Medicine, University of Oxford Nuffield Department of Orthopaedics Rheumatology and Musculoskeletal Sciences, Oxford, UK
| | - Matthew Greenhawt
- Section of Allergy and Clinical Immunology, Children's Hospital Colorado, Aurora, Colorado, USA
| | - Janet A Curran
- Pediatrics, IWK Health Centre, Halifax, Nova Scotia, Canada
| | - Roger Zemek
- Department of Pediatrics and Emergency Medicine, University of Ottawa Faculty of Medicine, Ottawa, Ontario, Canada
- Children's Hospital of Eastern Ontario Research Institute, Ottawa, Ontario, Canada
| | - Suzanne Schuh
- Pediatrics, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Anne Ellis
- Division of Allergy and Immunology, Queen's University, Kingston, Ontario, Canada
| | | | - Cheryl Kreviazuk
- Children's Hospital of Eastern Ontario Research Institute, Ottawa, Ontario, Canada
| | - Andrew Dixon
- Department of Pediatrics, University of Alberta, Edmonton, Alberta, Canada
| | | | - Stephen B Freedman
- Departments of Pediatrics and Emergency Medicine, Alberta Children's Hospital, University of Calgary Cumming School of Medicine, Calgary, Alberta, Canada
| | - Jocelyn Gravel
- Centre Hospitalier Universitaire Sainte-Justine, Universite de Montreal, Montreal, Québec, Canada
| | - Naveen Poonai
- Departments of Paediatrics, Internal Medicine, Epidemiology & Biostatistics, Western University, London, Ontario, Canada
| | - Margitta Worm
- Division of Allergy and Immunology, Department of Dermatology and Allergy, Charite Universitatsmedizin Berlin, Berlin, Germany
| | - Amy C Plint
- Department of Pediatrics and Emergency Medicine, University of Ottawa Faculty of Medicine, Ottawa, Ontario, Canada
- Children's Hospital of Eastern Ontario Research Institute, Ottawa, Ontario, Canada
| |
Collapse
|
13
|
Poonai N, Freedman S, Newton A, Sawyer S, Gaucher N, Ali S, Miller M, Mater A, Fitzpatrick E, Jabbour M, Zemek R, Eltorki M, Doan Q. 1 Ambulatory care visits and admissions for suicidal ideation and self-harm in Canadian adolescents during the COVID-19 pandemic: a population-based analysis. Paediatr Child Health 2022. [PMCID: PMC9586102 DOI: 10.1093/pch/pxac100.000] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022] Open
Abstract
Background The COVID-19 pandemic has challenged the resiliency of Canada’s adolescent population. Understanding changes in mental healthcare utilization can shed light on the impact the pandemic has had on Canada’s youth. Objectives To assess if during the pandemic there has been an increase in the proportion of ambulatory care visits and admissions for suicidal ideation and self-harm among adolescents. Design/Methods This was a population-based, interrupted time-series analysis of adolescents 10-18 years presenting to an ambulatory care facility (including emergency department) or admitted to a healthcare facility with R458 (suicidal ideation and emotional symptoms), X60-69 (intentional self-poisoning), and X70-84 (intentional self-harm) codes based on the International Statistical Classification of Diseases and Related Health Problems, Tenth Revision, Canada (ICD-10-CA). We used the National Ambulatory Care Reporting System, Discharge Abstract Database, and Hospital Morbidity Database. The primary outcome was ambulatory care visits for a composite of suicidal ideation, intentional self-poisoning, and intentional self-harm. Results were stratified by age and sex and expressed as a rate (proportion of encounters with an outcome per 100 encounters). We compared the differences (delta) in slopes (average increase in outcomes) between April 1, 2015, to March 31, 2020, and April 1, 2020 to March 31, 2021 to determine if the expected rate (pre-pandemic) differed significantly from the observed rate (pandemic). Results From April 1, 2020, to March 31, 2021, compared to April 1, 2015, to March 31, 2020, the rate of ambulatory care visits and admissions for all conditions decreased. The average quarterly rate of ambulatory care visits for the composite among males 10-14 years, increased by 40.3%, from 0.57 to 0.8 (slope delta=0.1; 95% CI: 0.02, 0.18; p=0.012). Among females 10-14 years, the rate increased by 85.1%, from 1.81 to 3.35 (slope delta=0.7; 95% CI: 0.43, 0.97; p<0.001). Among males 15-18 years, the rate increased by 29.5%, from 1.56 to 2.02 (slope delta=0.13; 95% CI: -0.02, 0.28; p=0.078). Among females 15-18 years, the rate increased by 33.6%, from 3.18 to 4.25 (slope delta=0.26; 95% CI: -0.16, 0.68; p=0.192). The average quarterly rate of admissions was significant for females 10-14 years and increased by 27.7%, from 8.59 to 10.97 (slope delta=1.99; 95% CI: 0.57, 3.41; p=0.017). Conclusion The proportion of ambulatory care visits and admissions for emotional symptoms, suicidal ideation, and self-harm during the first year of the COVID-19 pandemic increased compared to pre-pandemic rates among adolescents 10-14 years in Canada. Our findings underscore the importance of promoting public health policies that mitigate the impact of pandemics on adolescent mental health.
Collapse
Affiliation(s)
| | - Stephen Freedman
- Alberta Children’s Hospital Research Institute, University of Calgary
| | | | | | | | | | | | - Ahmed Mater
- Jim Pattison Children’s Hospital, and University of Saskatchewan
| | | | | | | | | | | |
Collapse
|
14
|
Rezk E, Eltorki M, El-Dakhakhni W. Improving Skin Color Diversity in Cancer Detection: Deep Learning Approach. JMIR Dermatol 2022. [DOI: 10.2196/39143] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Background
The lack of dark skin images in pathologic skin lesions in dermatology resources hinders the accurate diagnosis of skin lesions in people of color. Artificial intelligence applications have further disadvantaged people of color because those applications are mainly trained with light skin color images.
Objective
The aim of this study is to develop a deep learning approach that generates realistic images of darker skin colors to improve dermatology data diversity for various malignant and benign lesions.
Methods
We collected skin clinical images for common malignant and benign skin conditions from DermNet NZ, the International Skin Imaging Collaboration, and Dermatology Atlas. Two deep learning methods, style transfer (ST) and deep blending (DB), were utilized to generate images with darker skin colors using the lighter skin images. The generated images were evaluated quantitively and qualitatively. Furthermore, a convolutional neural network (CNN) was trained using the generated images to assess the latter’s effect on skin lesion classification accuracy.
Results
Image quality assessment showed that the ST method outperformed DB, as the former achieved a lower loss of realism score of 0.23 (95% CI 0.19-0.27) compared to 0.63 (95% CI 0.59-0.67) for the DB method. In addition, ST achieved a higher disease presentation with a similarity score of 0.44 (95% CI 0.40-0.49) compared to 0.17 (95% CI 0.14-0.21) for the DB method. The qualitative assessment completed on masked participants indicated that ST-generated images exhibited high realism, whereby 62.2% (1511/2430) of the votes for the generated images were classified as real. Eight dermatologists correctly diagnosed the lesions in the generated images with an average rate of 0.75 (360 correct diagnoses out of 480) for several malignant and benign lesions. Finally, the classification accuracy and the area under the curve (AUC) of the model when considering the generated images were 0.76 (95% CI 0.72-0.79) and 0.72 (95% CI 0.67-0.77), respectively, compared to the accuracy of 0.56 (95% CI 0.52-0.60) and AUC of 0.63 (95% CI 0.58-0.68) for the model without considering the generated images.
Conclusions
Deep learning approaches can generate realistic skin lesion images that improve the skin color diversity of dermatology atlases. The diversified image bank, utilized herein to train a CNN, demonstrates the potential of developing generalizable artificial intelligence skin cancer diagnosis applications.
International Registered Report Identifier (IRRID)
RR2-10.2196/34896
Collapse
|
15
|
Newton AS, Prisnie K, Macdonald LA, Eltorki M, Finkelstein Y, Fitzpatrick E, Gagnon I, Greenfield B, Joubert GI, Katz LY, Lipman EL, Mater A, Plotnick LH, Porter R, Sawyer S, St John KA, Sukhera J, Szatmari P, Rasiah J, Steele M, Hall P, Thull-Freedman J, Taljaard M, Cappelli M, Clark SE, Cost KT, Round J, Cherry J, Monga S, Sareen J, Klassen TP, Freedman SB. An Innovative Model of Pediatric Emergency Department Mental Health Care: Protocol for a Multicenter Type 1 Effectiveness-Implementation Cluster Randomized Trial. J Am Acad Child Adolesc Psychiatry 2022; 61:946-948. [PMID: 35772868 DOI: 10.1016/j.jaac.2022.04.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [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: 10/18/2021] [Revised: 01/06/2022] [Accepted: 04/04/2022] [Indexed: 11/29/2022]
Abstract
Over the past decade, visits to American and Canadian emergency departments (EDs) for child and youth mental health care have increased substantially.1,2 Acute mental health crises can occur as a result of a variety of concerns, including those that are life threatening (eg, suicide attempts), pose safety concerns (eg, suicidal intentions, aggressive behaviors, alcohol and other drug use), and are physically distressing to the child or youth (eg, panic attacks). ED health care providers play a vital role in assessing the safety and well-being of the child or youth and referring them to services for ongoing care.3,4 During the ED visit, assessment and care should pinpoint risks, inform treatment, and consider family needs and preferences as part of a patient-centered approach. Yet, this approach to care is not widely adopted in EDs. Most EDs do not require the use of pediatric-specific mental health tools to guide assessments or have patient-centered procedures in place to guide the care of patients with mental health emergencies.5-7 Our team believes these limitations have led to the provision of acute mental health care that can lack sufficient quality and efficiency. This study protocol describes a trial designed to evaluate if a novel mental health care bundle that was co-designed with parents and youth results in greater improvements in the well-being of children and youth 30 days after seeking ED care for mental health and/or substance misuse concerns compared with existing care protocols. We hypothesize that the bundle will positively impact child and youth well-being, while also providing cost-effective health care system benefits.
Collapse
Affiliation(s)
| | - Kassi Prisnie
- Cumming School of Medicine, University of Calgary, Alberta
| | - Lee A Macdonald
- Planning and Performance, Alberta Health Services, Edmonton, Alberta
| | | | | | | | - Isabelle Gagnon
- School of Physical & Occupational Therapy, McGill University, Montreal, Quebec
| | - Brian Greenfield
- School of Medicine, Faculty of Medicine and Health Sciences, McGill University, Montreal, Quebec
| | - Gary I Joubert
- Schulich School of Medicine & Dentistry, University of Western Ontario, London, Ontario
| | | | | | - Ahmed Mater
- College of Medicine, University of Saskatchewan, Saskatoon, Saskatchewan
| | - Laurie H Plotnick
- School of Medicine, Faculty of Medicine and Health Sciences, McGill University, Montreal, Quebec
| | - Robert Porter
- Memorial University of Newfoundland, St. John's, Newfoundland
| | - Scott Sawyer
- Rady Faculty of Health Sciences, Winnipeg, Manitoba
| | | | - Javeed Sukhera
- Institute of Living and Hartford Hospital, Hartford, Connecticut
| | - Peter Szatmari
- Hospital for Sick Children, University of Toronto, Ontario; The Cundill Centre for Child and Youth Depression, Centre for Addiction and Mental Health, Toronto, Ontario, Canada
| | | | - Margaret Steele
- Memorial University of Newfoundland, St. John's, Newfoundland
| | - Patricia Hall
- Schulich School of Medicine & Dentistry, University of Western Ontario, London, Ontario
| | | | - Monica Taljaard
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario; School of Epidemiology and Public Health, University of Ottawa, Ottawa, Ontario
| | - Mario Cappelli
- Ontario Centre of Excellence for Child & Youth Mental Health, Ottawa, Ontario
| | - Sharon E Clark
- Mental Health and Addictions, IWK Health, Halifax, Nova Scotia
| | - Katherine T Cost
- Neurosciences and Mental Health, The Hospital for Sick Children, Toronto, Ontario
| | - Jeff Round
- Institute of Health Economics, Edmonton, Alberta
| | | | - Suneeta Monga
- Hospital for Sick Children, University of Toronto, Ontario
| | | | | | | | | |
Collapse
|
16
|
Rasiah J, Freedman S, Macdonald L, Prisnie K, Eltorki M, Finkelstein Y, Hopkin G, Santana MJ, Thull-Freedman J, Stang A, Prebeg M, Gagnon IJ, Steele M, Mater A, Katz L, Greenfield B, Plotnick L, Monga S, Lipman EL, Wright B, Dimitropoulos G, Porter R, Hurley K, Al Hamarneh YN, Newton A. Evaluation of parent and youth experiences in advisory groups as part of a mental healthcare clinical trial: protocol for a mixed-method study. BMJ Open 2022; 12:e059689. [PMID: 35715176 PMCID: PMC9207895 DOI: 10.1136/bmjopen-2021-059689] [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] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
INTRODUCTION Patient engagement in healthcare research is a necessity to ensure that research objectives align with priorities, outcomes and needs of the population under study, and to facilitate ease of implementation and adoption of findings. In clinical trials, there is an increasing focus on patient engagement during the planning and conduct of clinical trials due to the potential for ethical and methodological benefits. As patient engagement in clinical trials increases, there is a need to evaluate the approaches of these activities to contribute evidence on what is most appropriate and successful. The purpose of this study is to evaluate patient engagement processes and the activities of patient partners during and after a paediatric mental healthcare trial. METHODS AND ANALYSIS Using a mixed-methods study design, we will evaluate patient partners' engagement activities across set time-points during the trial and after trial completion. In this study, the term 'patient partner' is inclusive of two groups of people with lived experience: (1) caregivers (parents, formal/informal caregivers and family), and (2) youth (aged 15-24 years). Engagement will be evaluated using the participant and project questionnaires of the Public and Patient Engagement Evaluation Tool (PPEET), followed sequentially by semi-structured interviews. Quantitative data from the PPEET questionnaire will be analysed and reported using descriptive statistics. Data from open-ended questions from the PPEET questionnaires and semi-structured interviews will be analysed using thematic analysis. ETHICS AND DISSEMINATION Approval from Athabasca University Research Ethics Board will be obtained for this project. Findings will be disseminated at both academic and public venues whether in-person or online, and using platforms that are caregiver and youth friendly. TRIAL REGISTRATION NUMBER NCT04902391.
Collapse
Affiliation(s)
- Jananee Rasiah
- Faculty of Health Disciplines, Athabasca University, Athabasca, Alberta, Canada
- College of Health Sciences, University of Alberta, Edmonton, Alberta, Canada
| | - Stephen Freedman
- Departments of Pediatrics, Emergency Medicine and Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
- Pediatrics, The Hospital for Sick Children, Calgary, Alberta, Canada
| | - Lee Macdonald
- Planning and Performance, Alberta Health Services, Calgary, Alberta, Canada
| | - Kassi Prisnie
- Pediatrics, University of Calgary Cumming School of Medicine, Calgary, Alberta, Canada
| | - Mohamed Eltorki
- Pediatrics, McMaster University Faculty of Health Sciences, Hamilton, Ontario, Canada
| | - Yaron Finkelstein
- Pediatrics, University of Alberta Faculty of Medicine and Dentistry, Edmonton, Alberta, Canada
| | - Gareth Hopkin
- Institute of Health Economics, Edmonton, Alberta, Canada
| | - Maria-Jose Santana
- Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
| | - Jennifer Thull-Freedman
- Departments of Pediatrics and Emergency Medicine, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Antonia Stang
- Pediatrics, University of Calgary, Calgary, Alberta, Canada
- Pediatrics, Alberta Children's Hospital, Calgary, Alberta, Canada
| | - Matthew Prebeg
- Centre for Addiction and Mental Health, Toronto, Ontario, Canada
| | - Isabelle J Gagnon
- School of Physical and Occupational Therapy, McGill University, Montreal, Quebec, Canada
- Trauma Department, Montreal Children's Hospital, McGill University Health Center, Montreal, Quebec, Canada
| | - Margaret Steele
- Discipline of Psychiatry, Faculty of Medicine, Memorial University of Newfoundland, St. John's, Newfoundland, Canada
| | - Ahmed Mater
- Pediatrics, University of Saskatchewan, Saskatoon, Saskatchewan, Canada
| | - Laurence Katz
- Department of Psychiatry, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
| | | | | | - Suneeta Monga
- Department of Psychiatry, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Ellen Louise Lipman
- Psychiatry and Behavioural Neurosciences, McMaster University, Hamilton, Ontario, Canada
| | - Bruce Wright
- Pediatrics, University of Alberta Faculty of Medicine and Dentistry, Edmonton, Alberta, Canada
- Stollery Children's Hospital, Alberta Health Services, Edmonton, Alberta, Canada
| | | | - Robert Porter
- Department of Pediatrics, Faculty of Medicine, Memorial University of Newfoundland, St. John's, Newfoundland, Canada
| | - Katrina Hurley
- Emergency Medicine Deparment, Faculty of Medicine, Dalhousie University, Halifax, Nova Scotia, Canada
| | | | - Amanda Newton
- College of Health Sciences, University of Alberta, Edmonton, Alberta, Canada
| |
Collapse
|
17
|
Eltorki M, Busse JW, Freedman SB, Thompson G, Beattie K, Serbanescu C, Carciumaru R, Thabane L, Ali S. Intravenous ketorolac versus morphine in children presenting with suspected appendicitis: a pilot single-centre non-inferiority randomised controlled trial. BMJ Open 2022; 12:e056499. [PMID: 35383071 PMCID: PMC8984007 DOI: 10.1136/bmjopen-2021-056499] [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] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
OBJECTIVES Despite a lack of evidence demonstrating superiority to non-steroidal anti-inflammatory drugs, like ketorolac, that are associated with lower risk of harms, opioids remain the most prescribed analgesic for acute abdominal pain. In this pilot trial, we will assess the feasibility of a definitive trial comparing ketorolac with morphine in children with suspected appendicitis. We hypothesise that our study will be feasible based on a 40% consent rate. METHODS AND ANALYSIS A single-centre, non-inferiority, blinded (participant, clinician, investigators and outcome assessors), double-dummy randomised controlled trial of children aged 6-17 years presenting to a paediatric emergency department with ≤5 days of moderate to severe abdominal pain (≥5 on a Verbal Numerical Rating Scale) and are investigated for appendicitis. We will use variable randomised blocks of 4-6 and allocate participants in 1:1 ratio to receive either intravenous (IV) ketorolac 0.5 mg/kg+IV morphine placebo or IV morphine 0.1 mg/kg+IV ketorolac placebo. Analgesic co-intervention will be limited to acetaminophen (commonly used as first-line therapy). Participants in both groups will be allowed rescue therapy (morphine 0.5 mg/kg) within 60 min of our intervention. Our primary feasibility outcome is the proportion of eligible patients approached who provide informed consent and are enrolled in our trial. Our threshold for feasibility will be to achieve a ≥40% consent rate, and we will enrol 100 participants into our pilot trial. ETHICS AND DISSEMINATION Our study has received full approval by the Hamilton integrated Research Ethics Board. We will disseminate our study findings at national and international paediatric research conferences to garner interest and engage sites for a future multicentre definitive trial. TRIAL REGISTRATION NCT04528563, Pre-results.
Collapse
Affiliation(s)
- Mohamed Eltorki
- Pediatrics, McMaster University, Faculty of Health Sciences, Hamilton, Ontario, Canada
| | - Jason W Busse
- Department of Health Research Methods, Evidence & Impact, McMaster, Hamilton, Ontario, Canada
- Anesthesia, McMaster University, Hamilton, Ontario, Canada
| | | | - Graham Thompson
- Pediatrics, Alberta Children's Hospital, Calgary, Alberta, Canada
| | - Karen Beattie
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | | | - Redjana Carciumaru
- Pediatrics, McMaster University, Faculty of Health Sciences, Hamilton, Ontario, Canada
| | - Lehana Thabane
- Pediatrics, McMaster University, Faculty of Health Sciences, Hamilton, Ontario, Canada
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada
- St Joseph's Research Institute, St Joseph's Health Care, Hamilton, Ontario, Canada
| | - Samina Ali
- Pediatrics, Stollery Children's Hospital, Edmonton, Alberta, Canada
| |
Collapse
|
18
|
Rezk E, Eltorki M, El-Dakhakhni W. Leveraging Artificial Intelligence to Improve the Diversity of Dermatological Skin Color Pathology: Protocol for an Algorithm Development and Validation Study. JMIR Res Protoc 2022; 11:e34896. [PMID: 34983017 PMCID: PMC8941446 DOI: 10.2196/34896] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2021] [Revised: 12/23/2021] [Accepted: 01/04/2022] [Indexed: 01/26/2023] Open
Abstract
Background The paucity of dark skin images in dermatological textbooks and atlases is a reflection of racial injustice in medicine. The underrepresentation of dark skin images makes diagnosing skin pathology in people of color challenging. For conditions such as skin cancer, in which early diagnosis makes a difference between life and death, people of color have worse prognoses and lower survival rates than people with lighter skin tones as a result of delayed or incorrect diagnoses. Recent advances in artificial intelligence, such as deep learning, offer a potential solution that can be achieved by diversifying the mostly light-skin image repositories through generating images for darker skin tones. Thus, facilitating the development of inclusive cancer early diagnosis systems that are trained and tested on diverse images that truly represent human skin tones. Objective We aim to develop and evaluate an artificial intelligence–based skin cancer early detection system for all skin tones using clinical images. Methods This study consists of four phases: (1) Publicly available skin image repositories will be analyzed to quantify the underrepresentation of darker skin tones, (2) Images will be generated for the underrepresented skin tones, (3) Generated images will be extensively evaluated for realism and disease presentation with quantitative image quality assessment as well as qualitative human expert and nonexpert ratings, and (4) The images will be utilized with available light-skin images to develop a robust skin cancer early detection model. Results This study started in September 2020. The first phase of quantifying the underrepresentation of darker skin tones was completed in March 2021. The second phase of generating the images is in progress and will be completed by March 2022. The third phase is expected to be completed by May 2022, and the final phase is expected to be completed by September 2022. Conclusions This work is the first step toward expanding skin tone diversity in existing image databases to address the current gap in the underrepresentation of darker skin tones. Once validated, the image bank will be a valuable resource that can potentially be utilized in physician education and in research applications. Furthermore, generated images are expected to improve the generalizability of skin cancer detection. When completed, the model will assist family physicians and general practitioners in evaluating skin lesion severity and in efficient triaging for referral to expert dermatologists. In addition, the model can assist dermatologists in diagnosing skin lesions. International Registered Report Identifier (IRRID) DERR1-10.2196/34896
Collapse
Affiliation(s)
- Eman Rezk
- School of Computational Science and Engineering, McMaster University, Hamilton, ON, Canada
| | - Mohamed Eltorki
- Faculty of Health Sciences, McMaster University, Hamilton, ON, Canada
| | - Wael El-Dakhakhni
- School of Computational Science and Engineering, McMaster University, Hamilton, ON, Canada
| |
Collapse
|
19
|
Eltorki M, Leong R, Ratcliffe E. A241 KIWIFRUIT AND KIWIFRUIT EXTRACTS FOR TREATMENT OF CONSTIPATION: A SYSTEMATIC REVIEW AND META-ANALYSIS. J Can Assoc Gastroenterol 2022. [DOI: 10.1093/jcag/gwab049.240] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [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: 11/12/2022] Open
Abstract
Abstract
Aims
This systematic review and meta-analysis aimed to determine the effectiveness of kiwifruit or kiwifruit extracts in thetreatment of constipation.
Methods
Electronic databases were searched from inception until January 2021. Eligible studies enrolled participants with functional constipation (FC) or irritable bowel syndrome with constipation (IBS-C) with randomization to receive kiwifruit or kiwifruit extracts vs. any non-kiwifruit control. Standardized meandifference (SMD) or mean difference (MD) with confidence intervals (CI) were determined for the following outcomes: weekly frequency of spontaneous bowel movements (SBM) and Bristol Stool Scale (BSS). GRADE approach was used to rate the certainty of evidence. PROSPERO registration number CRD42020207365.
Results
Seven randomized controlled trials including 399 participants (82% female; mean age 42 years [Standard Deviation 14.6]) were included. Compared with placebo, kiwifruit extract might increase weekly frequency of SBM (MD 1.36; 95% CI -0.44 to 3.16) with low certainty evidence. Kiwifruit had an uncertain effecton BSS (SMD 1.54; 95% CI -1.33 to 4.41) with very low certainty evidence. Compared with psyllium, kiwifruitmay increase weekly SBM (MD 1.1; 95% CI -0.02 to 2.04) and may increase BSS (softer stools) (MD 0.63;95% CI 0.01 to 1.25) both with low certainty evidence. Compared to placebo, kiwifruit encapsulated extracts may result in an increase in minor adverse events (Relative Risk 4.58; 95% CI 0.79 to 26.4).
Conclusions
Among individuals with constipation, overall low certainty of evidence indicate that kiwifruit may increase SBM when compared to placebo or psyllium. Although overall results are promising, establishing therole of kiwifruit in FC or IBS-C requires large, methodologically rigorous trials.
Funding Agencies
None
Collapse
Affiliation(s)
- M Eltorki
- Pediatrics, McMaster University Faculty of Health Sciences, Hamilton, ON, Canada
| | - R Leong
- McMaster University Faculty of Health Sciences, Hamilton, ON, Canada
| | - E Ratcliffe
- Pediatrics, McMaster University, Hamilton, ON, Canada
| |
Collapse
|
20
|
Algrigri O, Mirza A, Rezk E, Pernica J, Eltorki M. 43 The Prevalence of Serious Bacterial Infections in Infants less than 90 Days with and without Features of a Viral Infection: A Retrospective Cohort Study. Paediatr Child Health 2021. [DOI: 10.1093/pch/pxab061.034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Abstract
Primary Subject area
Emergency Medicine - Paediatric
Background
Prior studies suggest the prevalence of serious bacterial infections (SBI) (i.e., urinary tract infection [UTI], bacteremia, or meningitis) is lower in infants with a viral infection compared to those with fever without a source (FWS) (2-3% vs. 10-15%).
Objectives
To determine the difference in proportion of SBI in infants with and without clinical features of a viral infection.
Design/Methods
A retrospective cohort study was done on a consecutive sample of infants ≤ 90 days seen at a pediatric ED over a 5-year period ending August 30, 2019. Eligible subjects had rectal temperatures ≥ 38°C, and had ≥ 1 screening test for SBI (urine, blood and/or cerebrospinal fluid cultures). Excluded were infants who received antibiotics in the past 7 days, had congenital anomalies, required intensive care, or were preterm. We defined a clinical viral infection as > 1 clinical features of a respiratory viral infection (new-onset sneezing, cough, rhinorrhea, or shortness of breath). UTI was defined as per American Academy of Pediatrics guidelines.
Results
We screened 7021 charts and 885 (12%) were eligible. Of these, 498 (56%) had a clinical viral infection and 387 (44%) did not. Blood and urine cultures were collected from 860 (97%) infants and 308 (35%) had a lumbar puncture. Overall, 84 (10%) infants had an SBI: 76 (9%) UTI, 6 (0.7%) isolated bacteremia, and 2 (0.2%) meningitis. Among those with clinical viral infection, 23 (5%) had SBI, compared to 61 (16%) without viral infection (risk difference [RD] 11%, 95% CI [7%, 15%]). Both cases of meningitis occurred in infants ≤28 days and without any viral symptoms. A logistic regression was done to ascertain the effects of clinical viral infection, known risk factors for sepsis, age ≤ 28 days, or a temperature ≥ 39°C on the likelihood of SBI. Of the 4 predictors, only clinical viral infection and the presence of known risk factors for sepsis were significantly associated with SBI (odds ratio [OR] 0.3, 95% CI [0.17, 0.48] and 2.5, 95% CI [1.4, 4.5], respectively). Proportions of contaminated blood culture and urine culture were 5% (95% CI [4%, 7%]) and 14% (95% CI [12%, 17%]), respectively.
Conclusion
SBI prevalence in infants without features of a viral infection on assessment is triple that of infants with viral symptoms. Contaminant blood and urine cultures are folds higher than true pathological cultures. Future research is needed to identify infants at low risk of SBI without invasive testing.
Collapse
Affiliation(s)
| | - Asma Mirza
- McMaster Children’s Hospital – McMaster University
| | | | | | | |
Collapse
|
21
|
Chaudhari H, Schneeweiss M, Rebinsky R, Rullo E, Eltorki M. An Advanced Nursing Directive for Children With Suspected Appendicitis: Protocol for a Quality Improvement Feasibility Study. JMIR Res Protoc 2021; 10:e33158. [PMID: 34668867 PMCID: PMC8567150 DOI: 10.2196/33158] [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] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2021] [Accepted: 09/03/2021] [Indexed: 11/13/2022] Open
Abstract
Background Pediatric appendicitis accounts for an estimated 7% to 10% of abdominal pain cases in the emergency department (ED). The diagnosis is time-consuming, and the investigative process depends on physician assessment, resulting in delays in diagnosis and therapeutic management. The utility of an advanced nursing directive (AND) to expedite this process is unclear and needs further exploration. Objective This study aims to describe key components of ED flow in patients with suspected appendicitis seen at a pediatric ED and pilot a directive that allows ED nurses to perform an order set that includes blood work, urine tests, analgesics, fluids, and an abdominal-pelvis ultrasound prior to physician assessment. Methods This study involves conducting a retrospective chart review alongside a quality improvement initiative to compare key ED flow metrics before and after AND implementation. Primary outcome measures include median time from ED triage assessment to ultrasound completion, analgesia administration, blood work results, and time to disposition (consult or discharge), alongside other key ED flow metrics for suspected appendicitis. Secondary outcomes will involve patient and caretaker satisfaction surveys. Descriptive statistics will be used to summarize the data. For differences in proportions, a chi-square test will be used. The Student t test will be used for continuous variables. A variable-controlled run chart will be performed to assess impact on ED flow metrics. Patient and family satisfaction surveys are administered immediately after the directive encounter and 7 days afterward. Results There are currently 3900 patients who have been screened, 344 patients who have been enrolled, and 90 patients who have received the medical directive since implementation in June 2020. Interim results on reduction of time to diagnostic and therapeutic ED flow parameters and satisfaction surveys are expected to be published in February 2022. The final study endpoint will be in June 2022. Conclusions This study proposes a novel protocol for improving the diagnosis and treatment of suspected pediatric appendicitis through implementation of an evidence-based AND. This model may provide a standardized, international pathway for management of common pediatric and adult emergencies. International Registered Report Identifier (IRRID) RR1-10.2196/33158
Collapse
Affiliation(s)
- Hanu Chaudhari
- Faculty of Health Sciences, McMaster University, Hamilton, ON, Canada
| | | | - Reid Rebinsky
- Faculty of Health Sciences, McMaster University, Hamilton, ON, Canada
| | - Enrico Rullo
- Faculty of Health Sciences, McMaster University, Hamilton, ON, Canada
| | - Mohamed Eltorki
- Department of Pediatrics, McMaster University, Hamilton, ON, Canada
| |
Collapse
|
22
|
Komsa K, Ngo Q, Eltorki M. 68 General Pediatric Skills – Are we Doing Enough During Training to Prepare Pediatricians for Practice? Paediatr Child Health 2020. [DOI: 10.1093/pch/pxaa068.067] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Abstract
Background
Exposure to and training in acute care during pediatrics residency training varies. Furthermore, there is evidence that pediatric and neonatal resuscitative skills, like cardiopulmonary resuscitation, and management of acute care patients is often lacking.1,2 Several studies have shown that only 2.5 of every 1000 pediatric emergency department patients require significant resuscitative efforts3. Thus training for such an event is extremely important because mastering the skills involved are less likely to come with experience. Currently, it is unknown how comfortable community pediatricians feel managing acute care situations, nor if their comfort level changes depending on where they are trained.
Objectives
Our study aimed to determine if the training general pediatricians receive is sufficient to achieve a high comfort level in acute care that is sustained after 5 years in practice. This study explored pediatricians’ comfort levels with pediatric and neonatal acute care, as set out by the objectives of training in pediatrics from the Royal College of Physicians and Surgeons of Canada.
Design/Methods
An anonymous cross-sectional survey was piloted to a random sample of pediatricians in the province of Ontario, obtained through the College of Physicians and Surgeons of Ontario. Demographic data regarding practice type and duration was collected as well as training data about courses done in Pediatric Advanced Life Support (PALS) and Neonatal Resuscitation Program (NRP).
Using a five-point Likert scale, pediatricians were asked to judge their comfort with different pediatric and neonatal acute care skills and clinical vignettes. Comfort level ranking ranged from 1 (very uncomfortable) to 5 (very comfortable). Skills included are listed in Figure 1. Baseline characteristics were described using frequency measures of proportions and medians and interquartile ranges when appropriate. For general pediatricians and specialists, we used the Mann-Whitney test to determine if there is a difference between the mean sum ranks of comfort level depending on whether the pediatrician was practicing for more or less than 5 years.
Results
One thousand surveys were mailed, of which 248 were completed (response rate = 24%). Among respondents, 142 (54%) practiced general pediatrics and 68 (32%) were specialists. The majority of respondents practiced in a city, large city or metropolis (84%). In total, 169 (81%) of all survey respondents and 37 (74%) of general pediatricians have been in practice for five years or more.
For all respondents, 150 (64%) felt comfortable or very comfortable with neonatal resuscitation team lead. There was no difference in comfort level with leading a neonatal resuscitation team based on years of practice (less than 5 years versus greater than and equal to 5 years) (p=0.69). This result did not change when considering the general pediatrician only (p=0.14).
Of all respondents, 113 (48%) felt comfortable or very comfortable with pediatric resuscitation team lead. There was a significant difference in comfort level with leading a pediatric resuscitation team based on years of practice (less than 5 years versus greater than and equal to five years) (p=0.03) with more comfort being seen over time. When analyzing only for general pediatricians, that difference became insignificant (p=0.07).
No difference was found in reported comfort in most skills and length of time in practice. However, comfort level is significantly positively correlated with the number of times a skill was performed. Interestingly, a significantly negative correlation was found between comfort level as pediatric resuscitation team lead and number of years in practice (p=0.03).
Conclusion
The findings of this pilot survey suggest that ensuring competence in acute care in residency training is of utmost importance given that comfort with pediatric and neonatal resuscitation appears to remain static over time. The skills that pediatricians report most discomfort in are a target for continuing professional development or should be revised in the objectives of training of pediatrics.
Collapse
|
23
|
Leung JS, Brar M, Eltorki M, Middleton K, Patel L, Doyle M, Ngo Q. Development of an in situ simulation-based continuing professional development curriculum in pediatric emergency medicine. Adv Simul (Lond) 2020; 5:12. [PMID: 32617177 PMCID: PMC7326623 DOI: 10.1186/s41077-020-00129-x] [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] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2019] [Accepted: 06/03/2020] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Continuing professional development (CPD) activities delivered by simulation to independently practicing physicians are becoming increasingly popular. At present, the educational potential of such simulations is limited by the inability to create effective curricula for the CPD audience. In contrast to medical trainees, CPD activities lack pre-defined learning expectations and, instead, emphasize self-directed learning, which may not encompass true learning needs. We hypothesize that we could generate an interprofessional CPD simulation curriculum for practicing pediatric emergency medicine (PEM) physicians in a single-center tertiary care hospital using a deliberative approach combined with Kern's six-step method of curriculum development. METHODS From a comprehensive core list of 94 possible PEM clinical presentations and procedures, we generated an 18-scenario CPD simulation curriculum. We conducted a comprehensive perceived and unperceived needs assessment on topics to include, incorporating opinions of faculty PEM physicians, hospital leadership, interprofessional colleagues, and expert opinion on patient benefit, simulation feasibility, and value of simulating the case for learning. To systematically rank items while balancing the needs of all stakeholders, we used a prioritization matrix to generate objective "priority scores." These scores were used by CPD planners to deliberately determine the simulation curriculum contents. RESULTS We describe a novel three-step CPD simulation curriculum design method involving (1) systematic and deliberate needs assessment, (2) systematic prioritization, and (3) curriculum synthesis. Of practicing PEM physicians, 17/20 responded to the perceived learning needs survey, while 6/6 leaders responded to the unperceived needs assessment. These ranked data were input to a five-variable prioritization matrix generating priority scores. Based on local needs, the highest 18 scoring clinical presentations and procedures were selected for final inclusion in a PEM CPD simulation curriculum. An interim survey of PEM physician (21/24 respondents) opinions was collected, with 90% finding educational value with the curriculum. The curriculum includes items not identified by self-directed learning that PEM physicians thought should be included. CONCLUSIONS We highlight a novel methodology for PEM physicians that can be adapted by other specialities when designing their own CPD simulation curriculum. This methodology objectively considers and prioritizes the needs of practicing physicians and stakeholders involved in CPD.
Collapse
Affiliation(s)
- James S. Leung
- Division of Pediatric Emergency Medicine, Department of Pediatrics, McMaster University, Health Sciences Centre, Room 2R014, 1280 Main Street W, Hamilton, ON L8N 3Z5 Canada
| | - Mandeep Brar
- Emergency Department – McMaster Children’s Hospital, Hamilton Health Sciences, Hamilton, ON Canada
| | - Mohamed Eltorki
- Division of Pediatric Emergency Medicine, Department of Pediatrics, McMaster University, Health Sciences Centre, Room 2R014, 1280 Main Street W, Hamilton, ON L8N 3Z5 Canada
| | - Kevin Middleton
- Simulation and Outreach, McMaster Children’s Hospital, Hamilton, Canada
- Department of Pediatrics, McMaster University, Hamilton, Canada
| | - Leanne Patel
- Emergency Department – McMaster Children’s Hospital, Hamilton Health Sciences, Hamilton, ON Canada
| | - Meagan Doyle
- Division of Pediatric Emergency Medicine, Department of Pediatrics, McMaster University, Health Sciences Centre, Room 2R014, 1280 Main Street W, Hamilton, ON L8N 3Z5 Canada
| | - Quang Ngo
- Division of Pediatric Emergency Medicine, Department of Pediatrics, McMaster University, Health Sciences Centre, Room 2R014, 1280 Main Street W, Hamilton, ON L8N 3Z5 Canada
| |
Collapse
|
24
|
Sharif S, Eltorki M. Massive air leak secondary to influenza B in a 7-year-old: A case report. Am J Emerg Med 2019; 38:1045.e3-1045.e6. [PMID: 31884026 DOI: 10.1016/j.ajem.2019.12.034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2019] [Revised: 12/17/2019] [Accepted: 12/17/2019] [Indexed: 10/25/2022] Open
Abstract
Influenza is an illness that affects individuals of all ages but its severity varies immensely: from the symptoms of a common cold to the deadly outbreak of the pandemic H1N1 strain in 2009. This case report describes the circumstances surrounding the critical illness of a healthy 7-year-old child who developed a massive air leak syndrome secondary to influenza B. She required the emergent insertion of a chest tube as well as intubation and mechanical ventilation. She developed severe acute respiratory distress syndrome and was strongly considered for being placed on extracorporeal membrane oxygenation. She was treated with ceftriaxone and oseltamivir and slowly improved over the course of 20 days. The purpose of this report is to illustrate the severity of influenza with an emphasis on prevention with vaccination.
Collapse
Affiliation(s)
- Sameer Sharif
- Department of Medicine, Division of Critical and Emergency Medicine, McMaster University, Hamilton, ON, Canada.
| | - Mohamed Eltorki
- Department of Pediatrics, McMaster University, Hamilton, ON, Canada
| |
Collapse
|
25
|
Rosic T, Duncan L, Wang L, Eltorki M, Boyle M, Sassi R, Bennett K, Brotherston L, Pires P, Akintan O, Lipman E. Trends and Predictors of Repeat Mental Health Visits to a Pediatric Emergency Department in Hamilton, Ontario. J Can Acad Child Adolesc Psychiatry 2019; 28:82-90. [PMID: 31447906 PMCID: PMC6691794] [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] [Subscribe] [Scholar Register] [Received: 03/26/2019] [Accepted: 06/25/2019] [Indexed: 06/10/2023]
Abstract
OBJECTIVE From 2007-2017, pediatric emergency department (ED) visits for mental health concerns increased by 66% in Canada, with repeat visits accounting for a significant proportion of all visits. Our objective was to examine patient and visit characteristics associated with repeat visits to a tertiary care pediatric ED for mental health concerns. METHOD Data were obtained from the administrative records of McMaster Children's Hospital ED for mental health-related visits from February 2013-December 2017. Data on 9,018 ED visits made by 4,976 unique patients were included in this study. Logistic regression analysis was used to examine characteristics associated with repeat visit within six months of index presentation. RESULTS 22% (n=1,088) of individuals returned to the ED for a mental health concern within six months following their index visit. A repeat visit within six months was associated with female sex (OR=1.19, p=0.019), age of 14-17 years (OR=1.42, p=0.016), receiving a risk assessment by the emergency psychiatry team (OR=1.63, p<0.001) and having an inpatient psychiatric admission (OR=1.67, p<0.001) at the index visit. Receiving anxiety-related discharge diagnoses at an index visit reduced the odds of a repeat visit within 6 months (OR=0.76, p=0.035), while receiving depression-related discharge diagnoses increased the odds of a repeat visit, but only for females (OR=1.3, p=0.011 vs. OR=0.93, p=0.589 for males). CONCLUSIONS We found that approximately one in five patients presenting to the ED for a mental health concern have a repeat visit within six months, consistent with previous studies. This study provides support for previously identified risk factors for repeat visits and offers information on interactions between patient sex and diagnosis.
Collapse
Affiliation(s)
- Tea Rosic
- Department of Psychiatry and Behavioral Neurosciences, McMaster University, Hamilton, Ontario, Canada
| | - Laura Duncan
- Department of Psychiatry and Behavioral Neurosciences, McMaster University, Hamilton, Ontario, Canada
- Offord Centre for Child Studies, Hamilton, Ontario, Canada
- Department of Health Research Evidence and Impact (formerly Clinical Epidemiology and Biostatistics), McMaster University, Hamilton, Ontario, Canada
| | - Li Wang
- Department of Psychiatry and Behavioral Neurosciences, McMaster University, Hamilton, Ontario, Canada
- Offord Centre for Child Studies, Hamilton, Ontario, Canada
- Department of Health Research Evidence and Impact (formerly Clinical Epidemiology and Biostatistics), McMaster University, Hamilton, Ontario, Canada
| | - Mohamed Eltorki
- Department of Pediatrics, McMaster University, Hamilton, Ontario, Canada
| | - Michael Boyle
- Department of Psychiatry and Behavioral Neurosciences, McMaster University, Hamilton, Ontario, Canada
- Offord Centre for Child Studies, Hamilton, Ontario, Canada
| | - Roberto Sassi
- Department of Psychiatry and Behavioral Neurosciences, McMaster University, Hamilton, Ontario, Canada
- Offord Centre for Child Studies, Hamilton, Ontario, Canada
| | - Kathryn Bennett
- Department of Psychiatry and Behavioral Neurosciences, McMaster University, Hamilton, Ontario, Canada
- Offord Centre for Child Studies, Hamilton, Ontario, Canada
- Department of Health Research Evidence and Impact (formerly Clinical Epidemiology and Biostatistics), McMaster University, Hamilton, Ontario, Canada
| | - Lawna Brotherston
- Child and Youth Mental Health Program, McMaster Children's Hospital, Hamilton, Ontario, Canada
| | - Paulo Pires
- Department of Psychiatry and Behavioral Neurosciences, McMaster University, Hamilton, Ontario, Canada
| | - Olabode Akintan
- Department of Psychiatry and Behavioral Neurosciences, McMaster University, Hamilton, Ontario, Canada
| | - Ellen Lipman
- Department of Psychiatry and Behavioral Neurosciences, McMaster University, Hamilton, Ontario, Canada
- Offord Centre for Child Studies, Hamilton, Ontario, Canada
| |
Collapse
|
26
|
Eltorki M, Bhattacharjee A, Khan M, Martin E, Shyleyko R, Freedman SB. Treatment failure in children diagnosed with constipation in a paediatric emergency department in relation to Rome III criteria. Paediatr Child Health 2019; 24:185-192. [PMID: 31110460 DOI: 10.1093/pch/pxy121] [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] [Subscribe] [Scholar Register] [Received: 11/28/2017] [Accepted: 06/29/2018] [Indexed: 11/14/2022] Open
Abstract
Objective To determine if treatment failure varies based on ROME III classification and adherence to guideline congruent therapy among children diagnosed in an emergency department with functional constipation. Methods Children aged 1 month to 18 years who were diagnosed with constipation in a paediatric emergency department underwent chart review and 7-day phone follow-up to complete the ROME III questionnaire, confirm treatments administered, and assess treatment failure. Participants were classified according to the ROME III criteria as having functional constipation (FC) or irritable bowel syndrome - constipation (IBS-C) subtype. The primary outcome was treatment failure defined as ≥ 2 of the following: 1) presenting symptom persistence; 2) < 1 bowel movement every other day; 3) pain/difficulty passing stools; and 4) abdominal pain between bowel movements. Results Five hundred and thirteen children completed follow-up; 40% (204/513) had FC, 23% (118/513) IBS-C, and 37% (191/513) did not meet either criteria. Treatment failure rates in children who received guideline congruent treatment were 28% (38/135) among those classified as FC and 43% (37/86) among those with IBS-C; P=0.02, a difference of 15% (95% confidence interval [CI]: 0.02, 0.27). On regression analysis, ROME III classification was not an independent predictor of treatment failure (odds ratio [OR]: 1.56 [95% CI: 0.97, 2.51]). At 7-day follow up, pain in between bowel movements was present in 22% (44/204) in FC patients versus 45% (53/118) of IBS-C patients; P=0.001. Conclusions Treatment failure rates in children who receive guideline congruent therapy are higher among those with IBS-C, however, after adjustment for known confounders the relationship was not statistically significant.
Collapse
Affiliation(s)
- Mohamed Eltorki
- Division of Pediatric Emergency Medicine, McMaster Children's Hospital, McMaster University, Hamilton, Ontario
| | - Amrita Bhattacharjee
- Department of Pediatrics, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alberta
| | - Maida Khan
- Faculty of Nursing, University of Calgary, Calgary, Alberta
| | - Elise Martin
- Faculty of Medicine, University of Ottawa, Ottawa, Ontario
| | - Robert Shyleyko
- Department of Pediatrics, Cumming School of Medicine, University of Calgary, Calgary, Alberta
| | - Stephen B Freedman
- Sections of Pediatric Emergency Medicine and Gastroenterology, Alberta Children's Hospital, Alberta Children's Hospital Research Institute, Cumming School of Medicine, University of Calgary, Calgary, Alberta
| |
Collapse
|
27
|
Freedman SB, Eltorki M, Chui L, Xie J, Feng S, MacDonald J, Dixon A, Ali S, Louie M, Lee BE, Osterreicher L, Thull-Freedman J. Province-Wide Review of Pediatric Shiga Toxin-Producing Escherichia coli Case Management. J Pediatr 2017; 180:184-190.e1. [PMID: 27745751 DOI: 10.1016/j.jpeds.2016.09.013] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [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: 06/01/2016] [Revised: 07/27/2016] [Accepted: 09/08/2016] [Indexed: 02/03/2023]
Abstract
OBJECTIVE To identify the gaps in the care of children infected with Shiga toxin-producing Escherichia coli (STEC), we sought to quantitate care received and management timelines. Such knowledge is crucial to the design of interventions to prevent the development of hemolytic uremic syndrome (HUS). STUDY DESIGN We conducted a retrospective case-series study of 78 children infected with STEC in Alberta, Canada, through the linkage of microbiology and laboratory results, telephone health advice records, hospital charts, physician billing submissions, and outpatient antimicrobial dispensing databases. Outcomes were the time intervals between initial presentation and reporting of positive culture result and symptom onset to HUS and to describe the proportions that had baseline blood work performed and received antibiotics. RESULTS Seventy-eight children infected with STEC were identified; 13% (10/78) developed HUS. Median time from initial presentation to laboratory stool sample receipt was 33 hours (IQR 18, 42); time to positive culture was 120 hours (IQR 86, 205). Time from symptom onset to HUS diagnosis was 188 ± 37 hours. Baseline blood tests were obtained in 74% (58/78) of infected children. Antibiotics were administered to 50% (5/10) of those who developed HUS and 22% (15/78) of those who did not; P = .11. The provincial telephone advice system received 31 calls regarding 24 children infected with STEC; 23% (7/31) of callers were recommended to seek emergency department care. CONCLUSIONS A significant proportion of children developed HUS following multiple interactions with the health care system. Delays in the confirmation of STEC infection occurred. There are numerous opportunities to improve the timing, monitoring, and interventions in children infected with STEC.
Collapse
Affiliation(s)
- Stephen B Freedman
- Sections of Pediatric Emergency Medicine and Gastroenterology, Department of Pediatrics, Alberta Children's Hospital, Alberta Children's Hospital Research Institute, University of Calgary, Calgary, Alberta, Canada.
| | - Mohamed Eltorki
- Division of Pediatric Emergency Medicine, McMaster Children's Hospital, McMaster University, Hamilton, Ontario, Canada
| | - Linda Chui
- Provincial Laboratory for Public Health, Edmonton, Alberta, Canada; Department of Laboratory Medicine and Pathology, University of Alberta, Edmonton, Alberta, Canada
| | - Jianling Xie
- Section of Pediatric Emergency Medicine, Alberta Children's Hospital, Department of Pediatrics, Alberta Children's Hospital Research Institute, University of Calgary, Calgary, Alberta, Canada
| | - Sharon Feng
- Faculty of Medicine & Dentistry, University of Alberta, Edmonton, Alberta, Canada
| | - Judy MacDonald
- Population, Public and Indigenous Health, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Andrew Dixon
- Department of Pediatrics, Faculty of Medicine & Dentistry, Women and Children's Health Research Institute, University of Alberta, Edmonton, Alberta
| | - Samina Ali
- Department of Pediatrics, Faculty of Medicine & Dentistry, Women and Children's Health Research Institute, University of Alberta, Edmonton, Alberta
| | - Marie Louie
- Provincial Laboratory for Public Health, Edmonton, Alberta, Canada; Department of Microbiology Immunology and Infectious Diseases, University of Calgary, Calgary, Alberta, Canada
| | - Bonita E Lee
- Department of Pediatrics, Faculty of Medicine & Dentistry, Women and Children's Health Research Institute, University of Alberta, Edmonton, Alberta
| | - Lara Osterreicher
- Provincial Clinical Programs, Health Link, Alberta Health Services, Edmonton, Alberta, Canada
| | - Jennifer Thull-Freedman
- Section of Pediatric Emergency Medicine, Alberta Children's Hospital, Department of Pediatrics, Alberta Children's Hospital Research Institute, University of Calgary, Calgary, Alberta, Canada
| |
Collapse
|
28
|
Eltorki M, Rosenfield D. Bronchiolitis: More Evidence, Fewer Interventions-Shifting Paradigms With Evidence-based Diagnostics. Acad Emerg Med 2017; 24:114-116. [PMID: 27664941 DOI: 10.1111/acem.13109] [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] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Affiliation(s)
- Mohamed Eltorki
- Division of Pediatric Emergency Medicine, McMaster Children's Hospital, McMaster University, Hamilton, Ontario
| | - Daniel Rosenfield
- Division of Paediatric Emergency Medicine, The Hospital for Sick Children & University of Toronto, Toronto, Ontario, Canada
| |
Collapse
|
29
|
Eltorki M, Martin E. Association between Rome III Diagnostic Criteria and Treatment Failure in Children Brought for Emergency Department Care. Paediatr Child Health 2016. [DOI: 10.1093/pch/21.supp5.e69b] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Abstract
BACKGROUND: Many children diagnosed with functional constipation (FC) in the ED in fact meet Rome III criteria for irritable bowel syndrome constipaion subtype (IBS-C). The frequency of this misdiagnosis and its relation to outcomes is unknown.
OBJECTIVES: To determine if treatment failure frequency differs based on Rome III diagnostic criteria classification in a cohort of ED children diagnosed by treating physicians as having constipation.
DESIGN/METHODS: We performed a prospective cohort study of children 1 month – 18 years of age who were diagnosed with or were treated as FC in a pediatric ED. ED chart data was abstracted and a follow-up call was performed 7 days post-ED visit to enable the completion of the ROME III functional intestinal disorder questionnaire, confirm treatments administered, and enable symptom resolution assessment. 'Adequate therapy' was defined in accordance with ESPGHAN/NASPGHAN consensus guidelines. Treatment failure was defined by ≥2 of the following: persistence of presenting symptom(s), bowel movement frequency <1 every other day, pain or difficulty passing stools, abdominal pain between bowel movements, and/or persistence of the ED chief complaint.
RESULTS: 929 potentially eligible children were identified; 237 were excluded. We failed to contact 162 patients and 17 refused consent. 513 (74%) completed day 7 follow up – 227 (44%) met FC ROME III criteria, 119 (23%) met IBS-C criteria and 167 (33%) did not meet IBS-C or FC criteria and were classified as ‘other’. Mean age was 6.1±3.9 years. Treatment failure occurred in 69 (30%) FC patients, 50 (43%) of those with IBS-C, and 41 (25%) of ‘other’ group; P=0.007. These differences persisted when only those receiving ‘adequate therapy’ (n=308) were included: 41 (28%) of FC and 16 (22%) of those in the ‘other’ group had persistent symptoms compared to 37 (43%) of IBS-C patients; P=0.008. Kaplan-Meier analysis revealed greater symptom persistence in children with IBS-C compared to those with FC (P<0.001). Those classified as FC were more likely to have abdominal distension (P=0.05) and tenderness (P=0.04) compared to the IBS-C.
CONCLUSION: Children diagnosed with constipation in an ED who fulfill ROME III irritable bowel syndrome (constipation subtype) criteria have a higher treatment failure rate at day 7 compared to functional constipation even when including only those who received adequate functinal constipation therapy. ROME III criteria can be employed to identify children with irritable bowel syndrome; such children might benefit from diagnosis specific therapy.
Collapse
|
30
|
Freedman SB, Xie J, Neufeld MS, Hamilton WL, Hartling L, Tarr PI, Nettel-Aguirre A, Chuck A, Lee B, Johnson D, Currie G, Talbot J, Jiang J, Dickinson J, Kellner J, MacDonald J, Svenson L, Chui L, Louie M, Lavoie M, Eltorki M, Vanderkooi O, Tellier R, Ali S, Drews S, Graham T, Pang XL. Shiga Toxin-Producing Escherichia coli Infection, Antibiotics, and Risk of Developing Hemolytic Uremic Syndrome: A Meta-analysis. Clin Infect Dis 2016; 62:1251-1258. [PMID: 26917812 DOI: 10.1093/cid/ciw099] [Citation(s) in RCA: 143] [Impact Index Per Article: 17.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2015] [Accepted: 01/13/2016] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND Antibiotic administration to individuals with Shiga toxin-producing Escherichia coli (STEC) infection remains controversial. We assessed if antibiotic administration to individuals with STEC infection is associated with development of hemolytic uremic syndrome (HUS). METHODS The analysis included studies published up to 29 April 2015, that provided data from patients (1) with STEC infection, (2) who received antibiotics, (3) who developed HUS, and (4) for whom data reported timing of antibiotic administration in relation to HUS. Risk of bias was assessed; strength of evidence was adjudicated. HUS was the primary outcome. Secondary outcomes restricted the analysis to low-risk-of-bias studies employing commonly used HUS criteria. Pooled estimates of the odds ratio (OR) were obtained using random-effects models. RESULTS Seventeen reports and 1896 patients met eligibility; 8 (47%) studies were retrospective, 5 (29%) were prospective cohort, 3 (18%) were case-control, and 1 was a trial. The pooled OR, including all studies, associating antibiotic administration and development of HUS was 1.33 (95% confidence interval [CI], .89-1.99; I(2) = 42%). The repeat analysis including only studies with a low risk of bias and those employing an appropriate definition of HUS yielded an OR of 2.24 (95% CI, 1.45-3.46; I(2) = 0%). CONCLUSIONS Overall, use of antibiotics was not associated with an increased risk of developing HUS; however, after excluding studies at high risk of bias and those that did not employ an acceptable definition of HUS, there was a significant association. Consequently, the use of antibiotics in individuals with STEC infections is not recommended.
Collapse
Affiliation(s)
- Stephen B Freedman
- Section of Gastroenterology, Alberta Children's Hospital, Alberta Children's Hospital Research Institute.,Section of Pediatric Emergency Medicine, Alberta Children's Hospital, University of Calgary, Canada
| | - Jianling Xie
- Section of Pediatric Emergency Medicine, Alberta Children's Hospital, University of Calgary, Canada
| | - Madisen S Neufeld
- Section of Pediatric Emergency Medicine, Alberta Children's Hospital, University of Calgary, Canada
| | - William L Hamilton
- University of Cambridge School of Clinical Medicine, Addenbrooke's Hospital, United Kingdom
| | - Lisa Hartling
- Alberta Research Centre for Health Evidence, Department of Pediatrics, University of Alberta, Edmonton, Canada
| | - Phillip I Tarr
- Division of Gastroenterology, Hepatology, and Nutrition, Department of Pediatrics, Washington University School of Medicine, St Louis, Missouri
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
31
|
Freedman SB, Lee BE, Louie M, Pang XL, Ali S, Chuck A, Chui L, Currie GR, Dickinson J, Drews SJ, Eltorki M, Graham T, Jiang X, Johnson DW, Kellner J, Lavoie M, MacDonald J, MacDonald S, Svenson LW, Talbot J, Tarr P, Tellier R, Vanderkooi OG. Alberta Provincial Pediatric EnTeric Infection TEam (APPETITE): epidemiology, emerging organisms, and economics. BMC Pediatr 2015; 15:89. [PMID: 26226953 PMCID: PMC4521468 DOI: 10.1186/s12887-015-0407-7] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/08/2015] [Accepted: 07/15/2015] [Indexed: 01/05/2023] Open
Abstract
Background Each year in Canada there are 5 million episodes of acute gastroenteritis (AGE) with up to 70 % attributed to an unidentified pathogen. Moreover, 90 % of individuals with AGE do not seek care when ill, thus, burden of disease estimates are limited by under-diagnosing and under-reporting. Further, little is known about the pathogens causing AGE as the majority of episodes are attributed to an “unidentified” etiology. Our team has two main objectives: 1) to improve health through enhanced enteric pathogen identification; 2) to develop economic models incorporating pathogen burden and societal preferences to inform enteric vaccine decision making. Methods/Design This project involves multiple stages: 1) Molecular microbiology experts will participate in a modified Delphi process designed to define criteria to aid in interpreting positive molecular enteric pathogen test results. 2) Clinical data and specimens will be collected from children aged 0–18 years, with vomiting and/or diarrhea who seek medical care in emergency departments, primary care clinics and from those who contact a provincial medical advice line but who do not seek care. Samples to be collected will include stool, rectal swabs (N = 2), and an oral swab. Specimens will be tested employing 1) stool culture; 2) in-house multiplex (N = 5) viral polymerase chain reaction (PCR) panel; and 3) multi-target (N = 15) PCR commercially available array. All participants will have follow-up data collected 14 days later to enable calculation of a Modified Vesikari Scale score and a Burden of Disease Index. Specimens will also be collected from asymptomatic children during their well child vaccination visits to a provincial public health clinic. Following the completion of the initial phases, discrete choice experiments will be conducted to enable a better understanding of societal preferences for diagnostic testing and vaccine policy. All of the results obtained will be integrated into economic models. Discussion This study is collecting novel samples (e.g., oral swabs) from previously untested groups of children (e.g., those not seeking medical care) which are then undergoing extensive molecular testing to shed a new perspective on the epidemiology of AGE. The knowledge gained will provide the broadest understanding of the epidemiology of vomiting and diarrhea of children to date.
Collapse
Affiliation(s)
- Stephen B Freedman
- Department of Pediatrics, Sections of Pediatric Emergency Medicine and Gastroenterology, Alberta Children's Hospital, Alberta Children's Hospital Research Institute, University of Calgary, Calgary, AB, Canada.
| | - Bonita E Lee
- Department of Pediatrics, Stollery Children's Hospital, University of Alberta, Edmonton, AB, Canada.
| | - Marie Louie
- Provincial Laboratory for Public Health (ProvLab, Alberta Health Services), Departments of Microbiology, Immunology & Infectious Disease and Pathology & Laboratory Medicine, University of Calgary, Calgary, AB, Canada.
| | - Xiao-Li Pang
- Department of Laboratory Medicine & Pathology, University of Alberta, Edmonton, AB, Canada.
| | - Samina Ali
- Department of Pediatrics & Emergency Medicine, University of Alberta, Faculty of Medicine & Dentistry, Women and Children's Health Research Institute, Stollery Children's Hospital, Edmonton, AB, Canada.
| | - Andy Chuck
- Institute of Health Economics, Edmonton, AB, Canada.
| | - Linda Chui
- University of Alberta, Edmonton, AB, Canada.
| | - Gillian R Currie
- Department of Pediatrics, Alberta Children's Hospital Research Institute, O'Brien Institute of Public Health, University of Calgary, Calgary, AB, Canada. .,Department of Community Health Sciences, Alberta Children's Hospital Research Institute, O'Brien Institute of Public Health, University of Calgary, Calgary, AB, Canada.
| | - James Dickinson
- Departments of Family Medicine and Community Health Sciences, University of Calgary, Calgary, AB, Canada.
| | - Steven J Drews
- Department of Laboratory Medicine & Pathology, University of Alberta, Edmonton, AB, Canada.
| | - Mohamed Eltorki
- Department of Pediatrics, Section of Pediatric Emergency Medicine, Alberta Children's Hospital, University of Calgary, Calgary, AB, Canada.
| | - Tim Graham
- Department of Emergency Medicine, University of Alberta, Edmonton, AB, Canada.
| | - Xi Jiang
- Division of Infectious Diseases, Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, USA.
| | - David W Johnson
- Departments of Pediatrics and Physiology and Pharmacology, Section of Pediatric Emergency Medicine, Alberta Children's Hospital, Alberta Children's Hospital Research Institute, University of Calgary, Calgary, AB, Canada.
| | - James Kellner
- Department of Pediatrics, Section of Infectious Diseases, Alberta Children's Hospital, Alberta Children's Hospital Research Institute, University of Calgary, Calgary, AB, Canada.
| | - Martin Lavoie
- Alberta Health, University of Alberta, Edmonton, AB, Canada.
| | - Judy MacDonald
- Alberta Health Services, Department of Community Health Sciences, University of Calgary, Calgary, AB, Canada.
| | - Shannon MacDonald
- Department of Pediatrics, University of Calgary, Edmonton, AB, Canada. .,Faculty of Nursing, University of Alberta, Edmonton, AB, Canada.
| | | | - James Talbot
- Alberta Health, University of Alberta, Edmonton, AB, Canada.
| | - Phillip Tarr
- Division of Gastroenterology, Washington University, St. Louis, MO, USA.
| | - Raymond Tellier
- Department of Microbiology, Immunology and Infectious Disease, University of Calgary, Calgary, AB, Canada.
| | - Otto G Vanderkooi
- Department of Pediatrics, Section of Infectious Diseases, Alberta Children's Hospital Research Institute, University of Calgary, Calgary, AB, Canada. .,Department of Pathology and Laboratory Medicine, Section of Microbiology, Alberta Children's Hospital Research Institute, University of Calgary, Calgary, AB, Canada. .,Department of Microbiology, Immunology & Infectious Diseases, Alberta Children's Hospital Research Institute, University of Calgary, Calgary, AB, Canada.
| |
Collapse
|
32
|
Affiliation(s)
- Mohamed Eltorki
- Pediatric Emergency Medicine Fellow, University of Calgary, Alberta Children's Hospital, Calgary, Alberta E-mail
| |
Collapse
|
33
|
Freedman SB, Thull-Freedman J, Manson D, Rowe MF, Rumantir M, Eltorki M, Schuh S. Pediatric abdominal radiograph use, constipation, and significant misdiagnoses. J Pediatr 2014; 164:83-88.e2. [PMID: 24128647 DOI: 10.1016/j.jpeds.2013.08.074] [Citation(s) in RCA: 42] [Impact Index Per Article: 4.2] [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: 05/14/2013] [Revised: 08/09/2013] [Accepted: 08/30/2013] [Indexed: 01/10/2023]
Abstract
OBJECTIVE To determine the proportion of children diagnosed with constipation assigned a significant alternative diagnosis within 7 days (misdiagnosis), if there is an association between abdominal radiograph (AXR) performance and misdiagnosis, and features that might identify children with misdiagnoses. STUDY DESIGN We conducted a retrospective cohort study of consecutive children <18 years who presented to a pediatric emergency department in Toronto, between 2008 and 2010. Children assigned an International Statistical Classification of Diseases and Related Health Problems 10th Revision code consistent with constipation were eligible. Misdiagnosis was defined as an alternative diagnosis during the subsequent 7 days that resulted in hospitalization or an outpatient procedure that included a surgical or radiologic intervention. Constipation severity was classified employing text word categorization and the Leech score. RESULTS 3685 eligible visits were identified. Mean age was 6.6 ± 4.4 years. AXR was performed in 46% (1693/3685). Twenty misdiagnoses (0.5%; 95% CI 0.4, 0.8) were identified (appendicitis [7%], intussusception [2%, bowel obstruction [2%], other [9%]). AXR was performed more frequently in misdiagnosed children (75% vs 46%; P = .01). These children more often had abdominal pain (70% vs 49%; P = .04) and tenderness (60% vs 32%; P =.01). Children in both groups had similar amounts of stool on AXR (P = .38) and mean Leech scores (misdiagnosed = 7.9 ± 3.4; not misdiagnosed = 7.7 ± 2.9; P = .85). CONCLUSIONS Misdiagnoses in children with constipation are more frequent in those in whom an AXR was performed and those with abdominal pain and tenderness. The performance of an AXR may indicate diagnostic uncertainty; in such cases, the presence of stool on AXR does not rule out an alternative diagnosis.
Collapse
Affiliation(s)
- Stephen B Freedman
- Divisions of Pediatric Emergency Medicine and Gastroenterology, Hepatology and Nutrition, Department of Pediatrics, The Hospital for Sick Children, and Child Health Evaluative Sciences, The Hospital for Sick Children Research Institute, Faculty of Medicine, University of Toronto, Toronto, ON.
| | - Jennifer Thull-Freedman
- Division of Pediatric Emergency Medicine, Department of Pediatrics, The Hospital for Sick Children, Faculty of Medicine, University of Toronto, Toronto, ON
| | - David Manson
- Department of Diagnostic Imaging, Hospital for Sick Children, Division of Pediatric Imaging, Department of Medical Imaging, University of Toronto, Toronto, ON
| | - Margot Follett Rowe
- Division of Pediatric Emergency Medicine, The Hospital for Sick Children, Toronto, ON
| | - Maggie Rumantir
- Division of Pediatric Emergency Medicine, Department of Pediatrics, The Hospital for Sick Children, Faculty of Medicine, University of Toronto, Toronto, ON
| | - Mohamed Eltorki
- Department of Pediatrics, The Hospital for Sick Children, Faculty of Medicine, University of Toronto, Toronto, ON
| | - Suzanne Schuh
- Division of Pediatric Emergency Medicine, Department of Pediatrics, The Hospital for Sick Children, and Child Health Evaluative Sciences, The Hospital for Sick Children Research Institute, Faculty of Medicine, University of Toronto, Toronto, ON
| |
Collapse
|
34
|
Eltorki M, Uleryk E, Freedman SB. Waiver of informed consent in pediatric resuscitation research: a systematic review. Acad Emerg Med 2013; 20:822-34. [PMID: 24033626 DOI: 10.1111/acem.12180] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2012] [Revised: 03/07/2013] [Accepted: 03/11/2013] [Indexed: 11/28/2022]
Abstract
BACKGROUND In critical care and emergency medicine research, obtaining consent can be problematic when patients present with life-threatening conditions. This issue is further complicated in children, as even while coherent, they are often incapable of making decisions regarding their own care. To enable the ethical conduct of research in such situations, the Food and Drug Administration (FDA) of the United States has set recommendations for the conduct of research employing a waiver of consent. These regulations have been termed "exception from informed consent," or EFIC. As this is an evolving concept with limited pediatric experience, the authors conducted a review to examine the conduct of emergency research in the absence of prospectively obtained informed consent. Our review focused both on opinions and on the ability to conduct research without informed consent in life-threatening situations. METHODS A systematic review of the literature was undertaken in accordance with the PRISMA guidelines. Medline, CINAHL, and EMBASE databases were searched on January 9, 2013. Eligibility criteria included: 1) examined a method of conducting research in a life-threatening situation, 2) involved a real or theoretical clinical situation, 3) involved patients less than 18 years of age or a substitute decision-maker, and 4) reported at least one quantifiable outcome. The findings were synthesized qualitatively with the pertinent results summarized and discussed. RESULTS Eleven articles matched the eligibility criteria. Six focused on community consultation and public disclosure, three focused on the feasibility of employing a waiver of consent, and two examined attitudes toward emergency research. Of the studies focusing on community consultation, four defined the community as previous or current patients and health care providers and administrators in the study's home institution; the other two defined the community as the general population. Although there was heterogeneity in study designs, settings, and outcome measures, overall 68% (3,219 of 4,767) of subjects surveyed supported the use of EFIC under select circumstances (individual study range = 50% to 92%). Caregiver support increased among those in whom the situation was a more possible reality (e.g., critical care unit patients) and varied by the scenario and method of presentation (e.g., bulleted handout vs. preferred). Several studies revealed that patient accrual and time to intervention are impeded when prospective informed consent is required. Finally, deferred consent, although endorsed and used outside of the United States, continues to raise important ethical questions, particularly related to the need and timing of disclosure. CONCLUSIONS Limited data exist evaluating ethical issues in pediatric acute care resuscitation research. This review highlighted the fact that every proposal is unique and the method of obtaining consent (or waiver) requires careful consideration by local ethics committees. Particular attention must be paid to use of the population selected for community consultation. Several studies highlighted the need to consider the use of alternatives to prospective informed consent to enable the conduct of research in emergency departments (EDs) in life-threatening situations. Future research should evaluate children's opinions on this topic.
Collapse
Affiliation(s)
- Mohamed Eltorki
- Department of Paediatrics; The Hospital for Sick Children; University of Toronto; Toronto; Ontario; Canada
| | - Elizabeth Uleryk
- Department of Hospital Library and Archives; The Hospital for Sick Children; University of Toronto; Toronto; Ontario; Canada
| | | |
Collapse
|
35
|
Rosenfield D, Eltorki M, Bryden P. Addressing paediatric mental health concerns. Paediatr Child Health 2013; 18:293-294. [PMID: 24421694 PMCID: PMC3680248] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/08/2013] [Indexed: 06/03/2023] Open
Affiliation(s)
| | | | - Pier Bryden
- Department of Psychiatry, The Hospital for Sick Children, Toronto, Ontario
| |
Collapse
|