Parents of Very Young Children with Congenital Heart Defects Report Good Quality of Life for Their Children and Families Regardless of Defect Severity

The purpose of this study was to investigate parent reports of quality of life for their very young children with congenital heart defects (CHD) and to compare their scores to previously published data. Parents of children 1-3 years old with CHD or innocent heart murmurs completed the Pediatric Quality of Life Inventory (PedsQL) core, cardiac, and family impact modules. Multivariable regression analyses assessed the impact of age, sex, family income, and CHD treatment history (study group) on PedsQL scores. Correlations between family impact and core/cardiac modules were examined. PedsQL scores were compared to healthy norms. 140 parents of young children participated within four study groups: CHD no treatment (n = 44), CHD treatment without bypass (n = 26), CHD treatment with bypass (n = 42) ,and innocent heart murmurs (n = 28). Male sex was associated with higher core (F = 4.16, p = 0.04, σ² = .03) and cardiac quality of life (F = 4.41, p = .04, σ² = 0.04). Higher family income was associated with higher family quality of life (F = 8.89, p < .01, σ² = 0.13). Parents of children with innocent heart murmurs and children with CHD not requiring treatment had higher core quality of life compared to young healthy children. Cardiac-related quality of life scores were associated with family impact (r = 0.68) and core module (r = 0.63) quality of life scores. Parents of very young children with CHD report good quality of life for their children and families. Quality of life exceeds in children with innocent murmurs or CHD not requiring repair. Parents report a lower quality of life among girls, and lower family quality of life is associated with lower family income.

Improving mental health care transitions for children and youth: a protocol to implement and evaluate an emergency department clinical pathway

Background

While the emergency department (ED) is often a first point of entry for children and youth with mental health (MH) concerns, there is a limited capacity to respond to MH needs in this setting. Child MH systems are typically fragmented among multiple ministries, organizations, and providers. Communication among these groups is often poor, resulting in gaps, particularly in transitions of care, for this vulnerable population. The evidence-based Emergency Department Mental Health Clinical Pathway (EDMHCP) was created with two main goals: (1) to guide risk assessment and disposition decision-making for children and youth presenting to the ED with MH concerns and (2) to provide a streamlined transition to follow-up services with community MH agencies (CMHAs) and other providers. The purpose of this paper is to describe our study protocol to implement and evaluate the EDMHCP.

Methods/design

This mixed methods health services research project will involve implementation and evaluation of the EDMHCP in four exemplar ED-CMHA dyads. The Theoretical Domains Framework will be used to develop a tailored intervention strategy to implement the EDMHCP. A multiple baseline study design and interrupted time-series analysis will be used to determine if the EDMHCP has improved health care utilization, medical management of the MH problems, and health sector coordination. The primary process outcome will be the proportion of patients with MH-specific recommendations documented in the health record. The primary service outcome will be the proportion of patients receiving the EDMHCP-recommended follow-up at 24-h or at 7 days. Data sources will include qualitative interviews, health record audits, administrative databases, and patient surveys. A concurrent process evaluation will be conducted to assess the degree of variability and fidelity in implementation across the sites.

Discussion

This paper presents a novel model for measuring the effects of the EDMHCP. Our development process will identify how the EDMHCP is best implemented among partner organizations to deliver evidence-based risk management of children and youth presenting with MH concerns. More broadly, it will contribute to the body of evidence supporting clinical pathway implementation within novel partnerships.

Trial registration

ClinicalTrials.gov (NCT02590302)

Reduction of noise in the neonatal intensive care unit using sound-activated noise meters

OBJECTIVES

To determine if sound-activated noise meters providing direct audit and visual feedback can reduce sound levels in a level 3 neonatal intensive care unit (NICU).

DESIGN/METHODS

Sound levels (in dB) were compared between a 2-month period with noise meters present but without visual signal fluctuation and a subsequent 2 months with the noise meters providing direct audit and visual feedback.

RESULTS

There was a significant increase in the percentage of time the sound level in the NICU was below 50 dB across all patient care areas (9.9%, 8.9% and 7.3%). This improvement was not observed in the desk area where there are no admitted patients. There was no change in the percentage of time the NICU was below 45 or 55 dB.

CONCLUSIONS

Sound-activated noise meters seem effective in reducing sound levels in patient care areas. Conversations may have moved to non-patient care areas preventing a similar change there.

Examining the effects of a targeted noise reduction program in a neonatal intensive care unit

OBJECTIVES

To determine whether implementation of a noise reduction policy followed by the addition of direct audit and feedback reduces noise levels in a tertiary-level neonatal intensive care unit (NICU).

STUDY DESIGN

Noise level data was collected in three phases: (1) baseline (preintervention), (2) immediately postimplementation of our noise reduction policy, (3) postunveiling of direct audit and feedback mechanism.

SETTING

A level 3 NICU in Ontario, Canada.

INTERVENTIONS

Noise reduction policy and a direct audit and feedback mechanism.

MAIN OUTCOME MEASURES

Average noise level.

RESULTS

The baseline level of noise in our unit consistently exceeds guidelines with an average baseline noise of 49 dB (±1.4). Our intervention resulted in a significant reduction in noise levels for one of the four areas in our NICU [-1.06 dB (-1.52, -0.6)], with a trend towards reduction in a second area (-0.21 dB (-0.6, 0.18)). Unexpectedly, two other areas experienced a significant increase in noise (2.05 dB (1.18, 2.94); 0.85 dB (0.11, 1.59)).

CONCLUSIONS

The baseline noise in the NICU consistently exceeds guidelines, but reductions in noise levels are achievable. Nonetheless, more work is needed to find the optimal NICU design and noise reduction strategy.

Successful nanolitre real-time PCR detection of respiratory pathogens in clinical specimens

We performed a proof-of-concept study to determine if human pathogens could be detected in clinical specimens using nanolitre-volume real-time PCR. Nanolitre PCR for Bordetella pertussis/B. parapertussis and respiratory syncytial virus (RSV) was performed on nasopharyngeal specimens and results compared with conventional methods. B. pertussis/B. parapertussis nanolitre PCR detection was 100% sensitive (20/20; 95% CI, 84-100%) and 100% specific (26/26; 95% CI, 87-100%). RSV nanolitre PCR was also 100% sensitive (21/21; 95% CI, 85-100%) and specific (25/25; 95%, CI 87-100%). Respiratory pathogens can be successfully detected in clinical specimens using nanolitre-volume PCR.

Excessive gestational weight gain predicts large for gestational age neonates independent of maternal body mass index

OBJECTIVE

To determine the effects of maternal pre-pregnancy body mass index (BMI) and gestational weight gain (GWG) on large-for-gestational-age (LGA) birth weight (≥90th % ile).

METHODS

We examined 4321 mother-infant pairs from the Ottawa and Kingston (OaK) birth cohort. Multivariate logistic regression (controlling for gestational and maternal age, pre-pregnancy weight, parity, smoking) were performed and odds ratios (ORs) calculated.

RESULTS

Prior to pregnancy, a total of 23.7% of women were overweight and 16.2% obese. Only 29.3% of women met GWG targets recommended by the Institute of Medicine (IOM), whereas 57.7% exceeded the guidelines. Adjusting for smoking, parity, age, maternal height, and achieving the IOM's recommended GWG, overweight (OR 1.99; 95%CI 1.17-3.37) or obese (OR 2.64; 95% CI 1.59-4.39) pre-pregnancy was associated with a higher rate of LGA compared to women with normal BMI. In the same model, exceeding GWG guidelines was associated with higher rates of LGA (OR 2.86; 95% CI 2.09-3.92), as was parity (OR 1.49; 95% CI 1.22-1.82). Smoking (OR 0.53; 95%CI 0.35-0.79) was associated with decreased rates of LGA. The adjusted association with LGA was also estimated for women who exceeded the GWG guidelines and were overweight (OR 3.59; 95% CI 2.60-4.95) or obese (OR 6.71; 95% CI 4.83-9.31).

CONCLUSION

Pregravid overweight or obesity and gaining in excess of the IOM 2009 GWG guidelines strongly increase a woman's chance of having a larger baby. Lifestyle interventions that aim to optimize GWG by incorporating healthy eating and exercise strategies during pregnancy should be investigated to determine their effects on LGA neonates and down-stream child obesity.

Is staging beneficial for Fowler-Stephens orchiopexy? A systematic review

PURPOSE

Fowler and Stephens showed that by dividing the spermatic vessels a high intra-abdominal testis could be placed in the scrotum. Testicular atrophy is a potential complication of this technique. We conducted a systematic review to determine whether single or 2-stage Fowler-Stephens orchiopexy results in better testicular viability.

MATERIALS AND METHODS

We searched electronic databases, clinical trial registries and gray literature. We included reports describing boys younger than 18 years with a primary outcome of "testicular viability and position." We performed a meta-analysis using random effects models. Heterogeneity was assessed using forest plot and I(2) statistic.

RESULTS

We identified 1,807 citations and included 61 articles. Single stage Fowler-Stephens orchiopexy was discussed in 9 articles, a 2-stage procedure in 36 and both approaches in 16. There were no randomized controlled trials, and most studies were cohort or case series. The pooled estimate of success rates was 80% for single stage Fowler-Stephens orchiopexy (95% CI 75 to 86) and 85% for 2-stage Fowler-Stephens orchiopexy (95% CI 81 to 90). The pooled odds ratio of single stage vs 2-stage Fowler-Stephens orchiopexy was 2.0 (95% CI 1.1 to 3.9) favoring the 2-stage procedure. There was no difference in the success rate between laparoscopic and open techniques in either single or 2-stage Fowler-Stephens orchiopexy. There was no evidence of asymmetry on the funnel plot. There were no complications reported with single stage, while ileus, hematoma and infection were the most common complications with 2-stage Fowler-Stephens orchiopexy.

CONCLUSIONS

Both techniques have a fairly high success rate but 2-stage Fowler-Stephens orchiopexy appears to carry a higher rate of success than the single stage approach (85% vs 80%, OR 2 in favor of 2-stage). Laparoscopic and open techniques had the same success rate. However, the level of evidence of the studies was low, and a study of a more robust design, such as a randomized controlled trial, should be performed.

Pain management during eye examinations for retinopathy of prematurity in preterm infants: a systematic review

AIM

To assess whether non-pharmacological and/or pharmacological measures lead to decreased pain during an eye examination in preterm infants.

METHODS

.

DESIGN

Systematic review.

SUBJECTS

Premature infants meeting the criteria for screening eye examination for retinopathy.

INTERVENTION

Databases were searched through the Ovid interface. Randomized and quasi-randomized controlled trials were included. Data were assessed independently by three reviewers.

MAIN OUTCOME MEASURES

Pain assessed by Premature Infant Pain Profile (PIPP) or physiological changes.

RESULTS

Eight studies were included and grouped according to intervention: oral sucrose (group 1), anaesthetic eye drops (group 2) and non-pharmacological measures (group 3). For group 1, the mean PIPP score with sucrose was 1.38 (WMD) (95% CI: 0.41-2.35) lower than that of placebo (p = 0.005). For group 2, one study showed a reduction of two points on the PIPP score with topical proparacaine, whereas another showed no benefit. For group 3, developmental care improved developmental scores and salivary cortisol in one study.

CONCLUSION

Sucrose reduced pain during the eye examination, whereas the efficacy of proparacaine was not consistent in the studies included. However, PIPP scores remained relatively high in all the studies; thus further research is required to delineate better pain reduction strategies.

Heat recovery ventilators prevent respiratory disorders in Inuit children

Inuit infants have high rates of reported hospitalization for respiratory infection, associated with overcrowding and reduced ventilation. We performed a randomized, double-blind, placebo controlled trial to determine whether home heat recovery ventilators (HRV) would improve ventilation and reduce the risk of respiratory illnesses in young Inuit children. Inuit children under 6 years of age living in several communities in Nunavut, Canada were randomized to receive an active or placebo HRV. We monitored respiratory symptoms, health center encounters, and indoor air quality for 6 months. HRVs were placed in 68 homes, and 51 houses could be analyzed. Subjects had a mean age of 26.8 months. Active HRVs brought indoor carbon dioxide concentrations to within recommended concentrations. Relative humidity was also reduced. Use of HRV, compared with placebo, was associated with a progressive fall in the odds ratio for reported wheeze of 12.3% per week (95%CI 1.9-21.6%, P = 0.022). Rates of reported rhinitis were significantly lower in the HRV group than the placebo group in month 1 (odds ratio 0.20, 95%CI 0.058-0.69, P = 0.011) and in month 4 (odds ratio 0.24, 95%CI 0.054-0.90, P = 0.035). There were no significant reductions in the number of health center encounters, and there were no hospitalizations. Use of HRVs was associated with in improvement in air quality and reductions in reported respiratory symptoms in Inuit children.

PRACTICAL IMPLICATIONS

Reduced ventilation is common in the houses of Inuit children in arctic Canada, and is associated with an increased risk of respiratory infection. Installation of HRV brings indoor carbon dioxide concentration, as a marker of adequate ventilation, to within recommended concentrations, although relative humidity is also reduced. Installation of HRV is associated with improvements in indoor air quality, and a reduced risk of wheezing and rhinitis not associated with cold air exposure in young Inuit children. Further research is required to explore traditional Inuit cultural attitudes about air movement in dwellings.

When and how to update systematic reviews

BACKGROUND

Systematic reviews are most helpful if they are up-to-date. We did a systematic review of strategies and methods describing when and how to update systematic reviews.

OBJECTIVES

To identify, describe and assess strategies and methods addressing: 1) when to update systematic reviews and 2) how to update systematic reviews.

SEARCH STRATEGY

We searched MEDLINE (1966 to December 2005), PsycINFO, the Cochrane Methodology Register (Issue 1, 2006), and hand searched the 2005 Cochrane Colloquium proceedings.

SELECTION CRITERIA

We included methodology reports, updated systematic reviews, commentaries, editorials, or other short reports describing the development, use, or comparison of strategies and methods for determining the need for updating or updating systematic reviews in healthcare.

DATA COLLECTION AND ANALYSIS

We abstracted information from each included report using a 15-item questionnaire. The strategies and methods for updating systematic reviews were assessed and compared descriptively with respect to their usefulness, comprehensiveness, advantages, and disadvantages.

MAIN RESULTS

Four updating strategies, one technique, and two statistical methods were identified. Three strategies addressed steps for updating and one strategy presented a model for assessing the need to update. One technique discussed the use of the "entry date" field in bibliographic searching. Statistical methods were cumulative meta-analysis and predicting when meta-analyses are outdated.

AUTHORS' CONCLUSIONS

Little research has been conducted on when and how to update systematic reviews and the feasibility and efficiency of the identified approaches is uncertain. These shortcomings should be addressed in future research.

Bisphosphonate therapy for children and adolescents with secondary osteoporosis

BACKGROUND

Children with chronic illnesses are at increased risk for reductions in bone strength and subsequent fractures (osteoporosis), either due to the impact of the underlying condition on skeletal development or due to the osteotoxic effect of medications (e.g., glucocorticoids) used to treat the chronic illness. Bisphosphonates are being administered with increasing frequency to children with secondary osteoporosis; however, the efficacy and harm of these agents remains unclear.

OBJECTIVES

To examine the efficacy and harm of bisphosphonate therapy in the treatment and prevention of secondary osteoporosis in children and adolescents.

SEARCH STRATEGY

We searched the Cochrane Central Register of Controlled Trials (Issue 4, 2006), MEDLINE, EMBASE, CINAHL and ISI Web of Science (inception-December 2006). Further literature was identified through expert contact, key author searches, scanning reference lists of included studies, and contacting bisphosphonate manufacturers.

SELECTION CRITERIA

Randomized, quasi-randomized, controlled clinical trials, cohort, and case controls of bisphosphonate(s) in children 0-18 years of age with at least one low-trauma fracture event or reductions in bone mineral density in the context of secondary osteoporosis.

DATA COLLECTION AND ANALYSIS

Two reviewers independently extracted data and assessed quality. Case series were used for supplemental harms-related data.

MAIN RESULTS

Six RCTs, two CCTs, and one prospective cohort (n=281 children) were included and classified into osteoporosis due to: 1) neuromuscular conditions (one RCT) and 2) chronic illness (five RCTs, two CCTs, one cohort). Bisphosphonates examined were oral alendronate, clodronate, and intravenous (IV) pamidronate. Study quality varied. Harms data from 23 case series (n=241 children) were used. Heterogeneity precluded statistically combining the results. Percent change or Z-score change in lumbar spine areal BMD from baseline were consistently reported. Two studies carried out between-group analyses; one showed no significant difference (using oral alendronate in anorexia nervosa) while the other demonstrated a treatment effect on lumbar spine with IV pamidronate in burn patients. Frequently reported harms included the acute phase reaction, followed by gastrointestinal complaints, and bone/muscle pain.

AUTHORS' CONCLUSIONS

The results justify further evaluation of bisphosphonates among children with secondary osteoporosis. However, the evidence does not support bisphosphonates as standard therapy. Short-term (3 years or less) bisphosphonate use appears to be well-tolerated. An accepted criterion for osteoporosis in children, a standardized approach to BMD reporting, and examining functional bone health outcomes (e.g., fracture rates) will allow for appropriate comparisons across studies.

Imputing variance estimates do not alter the conclusions of a meta-analysis with continuous outcomes: a case study of changes in renal function after living kidney donation

OBJECTIVE

To assess how different imputation methods used to account for missing variance data in primary studies influence tests of heterogeneity and pooled results from a meta-analysis with continuous outcomes.

STUDY DESIGN AND SETTING

Point and variance estimates for changes in serum creatinine, glomerular filtration rate, systolic blood pressure, and diastolic blood pressure were variably reported among 48 primary longitudinal studies of living kidney donors (71%-78% of point estimates were reported, 8%-13% of variance data were reported). We compared the results of meta-analysis, which either were restricted to available data or used four methods to impute missing variance data. These methods used reported P-values, reported nonparametric summaries, results from other similar studies using multiple imputation, or results from estimated correlation coefficients.

RESULTS

Significant heterogeneity was present in all four outcomes regardless of the imputation methods applied. The random effects point estimates and 95% confidence intervals varied little across imputation methods, and the differences were not clinically significant.

CONCLUSIONS

Different methods to impute the variance data in the primary studies did not alter the conclusions from this meta-analysis of continuous outcomes. Such reproducibility increases confidence in the results. However, as with most meta-analyses, there was no gold standard of truth, and results must be interpreted judiciously. The generalization of these findings to other meta-analyses, which differ in outcomes, missing data, or between-study heterogeneity, requires further consideration.

Male erectile dysfunction following spinal cord injury: a systematic review

STUDY DESIGN

Systematic review.

OBJECTIVE

To review sexuality in persons with spinal cord injuries (SCIs), and to report the effectiveness of erectile interventions.

METHODS

Reports from six databases (1966-2003), selected annual proceedings (1997-2002) and manufacturer's information were screened against eligibility criteria. Included reports were abstracted and data pooled from case-series reports regarding intracavernous injections and sildenafil.

RESULTS

From 2127 unique reports evaluated, 49 were included. Male sexual dysfunction was addressed in these reports of several interventions (behavioural therapy, topical agents, intraurethral alprosatadil, intracavernous injections, vacuum tumescence devices, penile implants, sacral stimulators and oral medication). Penile injections resulted in successful erectile function in 90% (95% CI: 83%, 97%) of men. Sildenafil resulted in 79% (95% CI: 68%, 90%) success; the difference in efficacy was not statistically significant. Five case-series reports involving 363 participants with penile implants demonstrated a high satisfaction rate, but a 10% complication rate.

CONCLUSIONS

A large body of evidence addressing sexuality in males focuses on erection. Penile injection, sildenafil and vacuum devices generally obviate the need for penile implants to address erectile dysfunction. Interventions may positively affect sexual activity in the short term. Long-term sexual adjustment and holistic approaches beyond erections remain to be studied. Rigorous study design and reporting, using common outcome measures, will facilitate higher quality research. This will positively impact patient care.

SPONSORSHIP

Agency for Healthcare Research and Quality, US Department of Health and Human Services, 2101 East Jefferson Street, Rockville, MD 20852, USA.

Fertility following spinal cord injury: a systematic review

STUDY DESIGN

Systematic review.

OBJECTIVES

To review systematically fertility of persons with spinal cord injuries (SCI) and their partners.

METHODS

Reports from six databases (1966-2003), selected annual proceedings (1997-2002) and manufacturer's information were screened against eligibility criteria. Searches covered female obstetrical issues, and the efficacy of vibration and electroejaculation for males, as well as advanced fertility (AF) treatments for partners of SCI males. Data were pooled from case-series reports on SCI males' ejaculation, and pregnancies and live births for partners of SCI males.

RESULTS

In all, 2,127 unique reports were evaluated, of which 66 reports were included. No studies investigated fertility in SCI females. Ejaculation interventions in the last decade resulted in response rates of 95% (95% confidence intervals (CI) 91%, 99%), with 100% response rate reported in several recent publications. A total of 13 studies (1993-2001) yielded pregnancy rates of 51% (95% CI 42%, 60%) in partners of SCI males. Of these, 11 studies (1993-2003) yielded live birth rates of 41% (95% CI 33%, 49%).

CONCLUSIONS

Fertility of SCI males is extensively studied. Semen for fertility purposes can generally be obtained using vibration and electroejaculation. AF techniques are increasing pregnancy rates. Research is needed to improve sperm quality. Freezing of sperm is unlikely to significantly improve fertility rates. Fertility of SCI females is addressed only in case reports and opinion articles. The opinion that female fertility is unaffected by SCI should be further investigated using appropriate research methodology.

H2-receptor antagonists in the treatment of functional (nonulcer) dyspepsia: a meta-analysis of randomized controlled clinical trials

AIM

To perform a meta-analysis evaluating the efficacy of H2-receptor antagonists in functional (nonulcer) dyspepsia.

SELECTION OF STUDIES

A Medline search was used to identify placebo controlled randomized clinical trials, using the subject headings dyspepsia and H2-receptor antagonist.

OUTCOME MEASURES

Global assessment by the patient of dyspepsia symptoms, improvement of epigastric pain and complete relief of epigastric pain.

RESULTS

Twenty-two studies met the inclusion criteria, 15 of which reported the active drug to be superior to placebo. Many studies suffered from suboptimal study design. The odds ratio in favour of active drug was 1.48 (95% confidence interval: 0.9-2.3) for global assessment of dyspepsia symptoms, 2.3 (95% CI: 1.6-3.3) for improvement of epigastric pain, and 1.8 (95% CI: 1.2-2.8) for complete relief of epigastric pain.

CONCLUSION

There is some evidence that H2-receptor antagonists are superior to placebo in functional dyspepsia, but larger studies evaluating higher doses of H2-receptor antagonists and of longer duration are necessary to determine the exact effect size.