SMaRT-PCR: sampling using masks and RT-PCR, a non-invasive diagnostic tool for paediatric pulmonary TB

BACKGROUND

Key challenges in paediatric TB diagnosis are invasive sampling and poor sensitivity of standard methods. This study demonstrates the diagnostic potential of non-invasive sampling of bioaerosols from children using SMaRT-PCR, comprising mask sampling combined with reverse transcriptase-polymerase chain reaction (RT-PCR) for TB.

METHODS

Exhaled bioaerosols were captured on modified N-95 masks in a 10-min talk-cough-breathe process from 51 children (30 with TB confirmed using standard sampling methods and 21 without TB) aged 2-15 years. All mask samples were tested using in-house RT-PCR for 16s and rpoB RNA transcripts. Additional mask samples from children with TB were tested using Xpert® MTB/RIF (n = 3) and Xpert® MTB/RIF Ultra (n = 27).

RESULTS

SMaRT-PCR sensitivity for detecting TB among treatment-naïve children was 96% if 16s or rpoB was present, and 75% if both genes were present, comparable to standard methods (71%) in the same cohort. Specificity was better for both genes, at 95%, than 85% for a single gene detection. Mask sampling with Xpert MTB/RIF or Ultra had a sensitivity of only 13%.

CONCLUSION

This is the first study to provide evidence for testing bioaerosols as a promising alternative for detecting paediatric TB. Sampling is non-invasive and simple, with the potential for point-of-care applications. This pilot study also suggests that RNA transcript-based detection may improve TB diagnostic sensitivity in children; however, further investigation is required to establish its adaptability in clinical settings..

Age and sex-related comparison of referral-based telemedicine service utilization during the COVID-19 pandemic in Ontario: a retrospective analysis

BACKGROUND

The COVID-19 pandemic has led to increased utilization of telemedicine services.

METHODS

A retrospective analysis of all referral-based ambulatory telemedicine services in Ontario from November 2019 to June 2021 was collected from the Ontario Health Insurance Plan (OHIP) billing database. Only fee-for-service billings were included in the present analysis. Coincident COVID-19 cases were obtained from Public Health Ontario. Comparisons were made based on age bracket, sex, telemedicine and in-person care.

RESULTS

Billings for telemedicine services in Ontario increased from $1.7 million CAD in November 2019 to $64 million CAD in April 2020 and the proportions reached a mean peak of 72% in April 2020 and declined to 46% in June 2021. A positive correlation was found between the use of telemedicine and COVID-19 cases (p = 0.05). The age group with the highest proportion of telemedicine use was the 10-20-year-olds, followed by the 20-50-year-olds (61 ± 9.0%, 55 ± 7.3%, p = 0.01). Both age groups remained above 50% telemedicine services at the end of the study period. There seemed to be higher utilization by females (females 54.2 ± 8.0%, males 47.9 ± 7.7%, ANCOVA p = 0.05) for all specialties, however, after adjusting for male to female ratio m:f of 0.952:1.0 according to the 2016 census, this was no longer significant.

CONCLUSIONS

The use of telemedicine services remained at a high level across groups, particularly the 10-50-year-olds. There were clear age preferences for using telemedicine. Studying these differences may provide insights into how the delivery of non-hospital-based medicine has changed during the COVID-19 pandemic.

Evaluating a Novel Infant Heart Rate Detector for Neonatal Resuscitation Efforts: Protocol for a Proof-of-Concept Study

BACKGROUND

Over 10 million newborns worldwide undergo resuscitation at birth each year. Pediatricians may use electrocardiogram (ECG), pulse oximetry (PO), and stethoscope in determining heart rate (HR), as HR guides the need for and steps of resuscitation. HR must be obtained quickly and accurately. Unfortunately, the current diagnostic modalities are either too slow, obtaining HR in more than a minute, or inaccurate. With time constraints, a reliable robust heart rate detector (HRD) modality is required. This paper discusses a protocol for conducting a methods-based comparison study to determine the HR accuracy of a novel real-time HRD based on 3D-printed dry-electrode single-lead ECG signals for cost-effective and quick HR determination. The HRD's HR results are compared to either clinical-grade ECG or PO monitors to ensure robustness and accuracy.

OBJECTIVE

The purpose of this study is to design and examine the feasibility of a proof-of-concept HRD that quickly obtains HR using biocompatible 3D-printed dry electrodes for single-lead neonatal ECG acquisition. This study uses a novel HRD and compares it to the gold-standard 3-lead clinical ECG or PO in a hospital setting.

METHODS

A cross-sectional study is planned to be conducted in the neonatal intensive care unit or postpartum unit of a large community teaching hospital in Toronto, Canada, from June 2023 to June 2024. In total, 50 newborns will be recruited for this study. The HRD and an ECG or PO monitor will be video recorded using a digital camera concurrently for 3 minutes for each newborn. Hardware-based signal processing and patent-pending embedded algorithm-based HR estimation techniques are applied directly to the raw collected single-lead ECG and displayed on the HRD in real time during video recordings. These data will be annotated and compared to the ECG or PO readings at the same points in time. Accuracy, F1-score, and other statistical metrics will be produced to determine the HRD's feasibility in providing reliable HR.

RESULTS

The study is ongoing. The projected end date for data collection is around July 2024.

CONCLUSIONS

The study will compare the novel patent-pending 3D-printed dry electrode-based HRD's real-time HR estimation techniques with the state-of-the-art clinical-grade ECG or PO monitors for HR accuracy and examines how fast the HRD provides reliable HR. The study will further provide recommendations and important improvements that can be made to implement the HRD for clinical applications, especially in neonatal resuscitation efforts. This work can be seen as a stepping stone in the development of robust dry-electrode single-lead ECG devices for HR estimations in the pediatric population.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/45512.

Impact of antegrade enema initiation on healthcare utilization in pediatric patients: A population-based cohort study

BACKGROUND

When constipation is refractory to first-line interventions, antegrade enema use may be considered. We aimed to assess the impact of this intervention on healthcare utilization.

METHODS

We conducted a population-based, quasi-experimental study with pre-post comparison of the intervention group and a non-equivalent control group using linked clinical and health administrative data from Ontario, Canada. Subjects included children (0-18 years) who underwent antegrade enema initiation from 2007 to 2020 and matched controls (4:1) from the general population. To assess the change in healthcare utilization following antegrade enema initiation, we used negative binomial generalized estimating equations with covariates selected a priori.

KEY RESULTS

One hundred thirty-eight subjects met eligibility criteria (appendicostomy = 55 (39.9%); cecostomy tube = 83 (60.1%)) and were matched to 550 controls. There was no significant difference in the change in the rate of hospitalizations (rate ratio (RR) 1.05, 95% confidence interval (CI) 0.35-1.75), outpatient visits (RR 1.05, 95% CI 0.91-1.18), or same-day surgical procedures (RR 1.51, 95% CI 0.60-2.43) across cases in 2 years following antegrade enema initiation compared with controls. Cases had an increased rate of emergency department (ED) visits, which was not observed in controls (RR 1.52, 95% CI 1.11-1.79), driven in part by device-related complications.

CONCLUSIONS AND INFERENCES

Understanding healthcare utilization patterns following antegrade enema initiation allows for effective health system planning and aids medical decision-making. The observed increase in ED visits for device-related complications speaks to the need to improve preventive management to help mitigate emergency care after initiation of antegrade enemas.

Utilization of a novel mobile application, "HBB Prompt", to reduce Helping Babies Breathe skills decay

BACKGROUND

Helping Babies Breathe (HBB) is a newborn resuscitation training program designed to reduce neonatal mortality in low- and middle-income countries. However, skills decay after initial training is a significant barrier to sustained impact.

OBJECTIVE

To test whether a mobile app, HBB Prompt, developed with user-centred design, helps improve skills and knowledge retention after HBB training.

METHODS

HBB Prompt was created during Phase 1 of this study with input from HBB facilitators and providers from Southwestern Uganda recruited from a national HBB provider registry. During Phase 2, healthcare workers (HCWs) in two community hospitals received HBB training. One hospital was randomly assigned as the intervention hospital, where trained HCWs had access to HBB Prompt, and the other served as control without HBB Prompt (NCT03577054). Participants were evaluated using the HBB 2.0 knowledge check and Objective Structured Clinical Exam, version B (OSCE B) immediately before and after training, and 6 months post-training. The primary outcome was difference in OSCE B scores immediately after training and 6 months post-training.

RESULTS

Twenty-nine HCWs were trained in HBB (17 in intervention, 12 in control). At 6 months, 10 HCW were evaluated in intervention and 7 in control. In intervention and control respectively, the median OSCE B scores were: 7 vs. 9 immediately before training, 17 vs. 21 immediately after training, and 12 vs. 13 at 6 months after training. Six months after training, the median difference in OSCE B scores was -3 (IQR -5 to -1) in intervention and -8 (IQR -11 to -6) in control (p = 0.02).

CONCLUSION

HBB Prompt, a mobile app created by user-centred design, improved retention of HBB skills at 6 months. However, skills decay remained high 6 months after training. Continued adaptation of HBB Prompt may further improve maintenance of HBB skills.

Use of timed alarm device for pediatric daytime urinary incontinence: Meta-analysis of comparative studies

Introduction: This meta-analysis aimed to determine the comparative effectiveness of timed alarm device-assisted urotherapy vs. standard urotherapy alone in managing pediatric daytime urinary incontinence (pDUI). Methods: A systematic literature search was performed in December 2021, with an update search in July 2022. Comparative studies assessing the pDUI treatment effectiveness of timed alarm device-assisted urotherapy vs. urotherapy alone were identified and evaluated according to Cochrane collaboration recommendations. The assessed outcome includes pDUI complete response and adherence rates. Relative risk (RR) with 95% confidence intervals (CI) was extrapolated. A random-effects model was used to pool effect estimates. Heterogeneity was assessed with sensitivity and subgroup analysis performed according to study design and comparative group characteristics. GRADE criteria were used to assess evidence certainty. PROSPERO (CRD42022299173). Results: Four studies (three randomized controlled trials [RCTs] and one retrospective cohort) with 635 cases were included. The pooled effect estimates of pDUI complete response showed no differences between intervention groups (RR 1.20, 95% CI 0.81, 1.76). Pooled effect estimates for treatment adherence were generated from two studies, which showed significantly better adherence for the timed-alarm device group (RR 2.97, 95% CI 1.46, 6.06). Significant interstudy heterogeneity was noted; the source is likely from the study design and comparator device characteristics. The quality of evidence was assessed to be of very low certainty. Conclusions: Based on very low certainty evidence, timed alarm device-assisted urotherapy does not seem to have the advantage of complete treatment response over standard urotherapy alone in managing pDUI; however, a timed-alarm device is likely able to improve urotherapy treatment adherence.

Case-control study of vitamin D status and adult multidrug-resistant pulmonary TB

BACKGROUND: India has the highest prevalence of multidrug-resistant TB (MDR-TB) globally. Vitamin D deficiency is potentially an important risk factor for MDR-TB.METHODS: We conducted a case-control study of 90 newly diagnosed adult MDR-TB cases, 180 household controls and 82 non-household controls in Mumbai, India. Serum 25-hydroxyvitamin D (25(OH)D), anthropometry, clinical status and history, dietary data and sociodemographic data were collected from each participant. Interferon-gamma release assay (IGRA) was also performed in controls to assess latent TB. Multivariable regression was performed to estimate associations between 25(OH)D vs. case status and IGRA positivity.RESULTS: Mean participant age was 33.8 ± 12.0 years; 72.8% had 25(OH)D <20 ng/ml. Mean 25(OH)D was significantly (P < 0.05) lower in cases (12.5 ± 7.9) than both household (17.5 ± 11.2) and non-household controls (16.4 ± 9.1). In multivariable models, 25(OH)D concentration was inversely associated with MDR-TB case status among cases and household controls (OR 0.95 per 1 ng/ml, 95% CI 0.92-0.99; P = 0.015), and among cases and non-household controls (OR 0.94 per 1 ng/ml, 95% CI 0.89-1.00; P = 0.033); 53.6% of controls were IGRA-positive. 25(OH)D status was not associated with IGRA positivity.CONCLUSION: Vitamin D status was independently associated with MDR-TB case status. Research should evaluate the effectiveness of vitamin D supplementation in prevention and adjunctive treatment of MDR-TB.

Neurodevelopmental and psychiatric disorders in pediatric bladder and bowel dysfunction

BACKGROUND

Bladder and bowel dysfunction (BBD) is a common pediatric problem that describes a constellation of lower urinary tract symptoms associated with constipation and/or encopresis. Its association with neurodevelopmental and psychiatric (NDP) problems is not well understood.

OBJECTIVES

Our primary aim was to identify pre-existing NDP disorders in children with BBD. Secondarily, we aimed to screen for new behavioral problems and evaluate the association between bladder or bowel symptoms and behaviors symptoms.

METHODS

A cross sectional study was conducted in urology clinics. New patients referred for BBD between 4 and 17 years old were recruited and completed: a demographics survey, Dysfunctional Voiding Score System questionnaire, assessment of bowel movements with the Bristol Stool Scale, and Strength and Difficulties questionnaire (SDQ). Those with known spinal dysraphism were excluded. SDQ scores were evaluated for abnormal screens in different subscales and total difficulties scores. Pearson correlation analyses were conducted for association.

RESULTS

We included 61 participants (age 9.5 ± 4.1 years), including 33 females and 28 males. One or more pre-existing NDP disorder(s) was reported in 14 (23%) children; most commonly being learning disability (43%) and attention deficit hyperactivity disorder (29%). This cohort had more severe BBD symptoms as reflected in DVSS scores. SDQ scores demonstrated that 12 patients without pre-existing NDP diagnoses scored in the clinical range, with hyperactivity as the most common difficulty (6/12; 50%).

CONCLUSIONS

A significant proportion of children with BBD have a comorbid NDP disorder and present with more severe symptomatology. The SDQ can be used as a behavioral screening tool this population for the identification of children who may benefit from formal developmental pediatrics assessment.

Bladder and Bowel Dysfunction Network: Improving the Management of Pediatric Bladder and Bowel Dysfunction

Lower urinary tract symptoms with constipation characterize bladder and bowel dysfunction (BBD). Due to high referral volumes to hospital pediatric urology clinics and time-consuming appointments, wait times are prolonged. Initial management consists of behavioral modification strategies that could be accomplished by community pediatricians. We aimed to create a network of community pediatricians trained in BBD (BBDN) management and assess its impact on care.

METHODS

We distributed a survey to pediatricians, and those interested attended training consisting of lectures and clinical shadowing. Patients referred to a hospital pediatric urology clinic were triaged to the BBDN and completed the dysfunctional voiding symptom score and satisfaction surveys at baseline and follow-up. The Bristol stool chart was used to assess constipation. Results were compared between BBDN and hospital clinic patients.

RESULTS

Surveyed pediatricians (n = 100) most commonly managed BBD with PEG3350 and dietary changes and were less likely to recommend bladder retraining strategies. Baseline characteristics were similar in BBDN (n = 100) and hospital clinic patients (n = 23). Both groups had similar improvements in dysfunctional voiding symptom score from baseline to follow-up (10.1 ± 4.2 to 5.6 ± 3.3, P = 0.01, versus 10.1 ± 4.2 to 7.8 ± 4.5, P = 0.02). BBDN patients waited less time for their follow-up visit with 56 (28-70) days versus 94.5 (85-109) days for hospital clinic patients (P < 0.001). Both groups demonstrated high familial satisfaction.

CONCLUSIONS

Community pediatricians may require more knowledge of management strategies for BBD. Our pilot study demonstrates that implementing a BBDN is feasible, results in shorter wait times, and similar improvement in symptoms and patient satisfaction than a hospital pediatric urology clinic.

Development of a novel mobile application, HBB Prompt, with human factors and user-centred design for Helping Babies Breathe skills retention in Uganda

BACKGROUND

Helping Babies Breathe (HBB) is a life-saving program that has helped reduce neonatal morbidity and mortality, but knowledge and skills retention after training remains a significant challenge for sustainability of impact. User-centred design (UCD) can be used to develop solutions to target knowledge and skills maintenance.

METHODS

We applied a process of UCD beginning with understanding the facilitators of, and barriers to, learning and retaining HBB knowledge and skills. HBB Master Trainers and frontline HBB providers participated in a series of focus group discussions (FGDs) to uncover the processes of skills acquisition and maintenance to develop a mobile application called "HBB Prompt". Themes derived from each FGD were identified and implications for development of the HBB Prompt app were explored, including feasibility of incorporating strategies into the format of an app. Data analysis took place after each iteration in Phase 1 to incorporate feedback and improve subsequent versions of HBB Prompt.

RESULTS

Six HBB trainers and seven frontline HBB providers participated in a series of FGDs in Phase 1 of this study. Common themes included lack of motivation to practise, improving confidence in ventilation skills, ability to achieve the Golden Minute, fear of forgetting knowledge or skills, importance of feedback, and peer-to-peer learning. Themes identified that were not feasible to address pertained to health system challenges. Feedback about HBB Prompt was generally positive. Based on initial and iterative feedback, HBB Prompt was created with four primary functions: Training Mode, Simulation Mode, Quizzes, and Dashboard/Scoreboard.

CONCLUSIONS

Developing HBB Prompt with UCD to help improve knowledge and skills retention was feasible and revealed key concepts, including drivers for successes and challenges faced for learning and maintaining HBB skills. HBB Prompt will be piloted in Phase 2 of this study, where knowledge and skills retention after HBB training will be compared between an intervention group with HBB Prompt and a control group without the app. Trial registration Clinicaltrials.gov (NCT03577054). Retrospectively registered July 5, 2018, https://clinicaltrials.gov/ct2/show/study/NCT03577054 .

47 Increase Clinic Attendance Among Adolescents and Young Adults: A novel cost-effective method

Background

Transition clinics have been introduced to address the unique needs of adolescent and young adult (AYA) populations, however clinic attendance continues to be an issue. Although poor clinic attendance among the AYA population has been well known, solutions to address this has been limited. Some factors that have been associated with missed appointments include forgetfulness, negative previous clinic experiences and clinic schedules. With widespread use of digital technologies among AYA, the application of digital solutions to increase attendance at healthcare appointments has been explored, but little is known on its effectiveness.

Objectives

To determine the effect of text messaging appointment reminders on uninformed no show rates in an AYA transition clinic. Uninformed no show rate was defined as an absence from clinic (not related to a medical emergency) without communication with the clinic.

Design/Methods

A pilot prospective cohort study with a retrospective control group was conducted in an AYA general hematology transition clinic. In order to establish the current no show rate at the clinic, a retrospective review of AYA patients who attended the clinic between April 2013-August 2015 was conducted. Thereafter, all patients who had an appointment scheduled between February 2016 and December 2017 were included in the study and received a text message reminder of their appointment 48 hours prior to their appointment. Monthly uninformed no show rates were collected, and a student’s t-test was conducted to determine if there was a significant difference in uninformed no show rates before and after the introduction of text message reminders.

Results

Eighty-six participants consented to participate in the study and received a text message reminder of their appointment. From April 2013- August 2015 a total of 51 clinic days with 236 appointments occurred. During this time the mean uninformed no show rate was 39.9%. SMS appointment reminders were sent from February 2016 to December 2017 for 48 clinic days for a total of 206 clinic appointments. The mean uninformed no show rate after the introduction of text message appointment reminders was 22.6%. The introduction of text messaging appointment reminders significantly (p&lt;0.01) decreased uninformed no show rates by 17.3%.

Conclusion

Text message reminders are an effective low cost method in reminding AYA patients about their appointments. By using innovative, cost effective and practical strategies like text messaging reminders to increase clinic attendance, we not only improve the care of our patients but also reduce the financial and clerical burden to the system resulting from missed appointments.

107 A Novel Transition Clinic For Adolescents and Young Adults With Non-Malignant Blood Disorders

Background

Transition clinics have been introduced as a way to address the unique needs of adolescent and young adult populations (AYA). AYA transition clinics for non-malignant blood disorders that require continuous care and management such as chronic immune thrombocytopenia (ITP) and Hereditary Spherocytosis (HS), have not been evaluated to date. In addition, the concerns and barriers to accessing care among this population have not been previously described.

Objectives

To explore the needs of AYA patients with a non-malignant hematological condition in order to improve their transition to the adult healthcare system through a transition clinic.

Design/Methods

A prospective cross-sectional survey study was conducted with AYA patients with a new or existing non-malignant hematological condition attending an AYA clinic in Toronto. Patients were prospectively provided a survey prior to their clinic appointment via text message.

Results

Twenty eight patients completed the survey. Most of the patients were female (84.6%) and between 16-25 years of age. Patients were in school (57%) or working (25%). Over half of the patients (53%) reported to seeing a doctor at least once a year. In order to attend clinic appointments, 61% reported taking public transportation, 10% of patients receive a ride from their family and 29% of patients either drove themselves or walked/biked to clinic. Twenty-seven percent of patients were unsure of their condition, 50% did not know the cause of their condition, and over 70% of patients were concerned about their health at least once a day. Almost all patients had concerns about transitioning to adult care with concerns including 1) Adult care not understanding their needs, 2) Increased responsibility of their care and 3) Working with a new clinical care team. Despite their concerns of transition to an adult healthcare system, 67% of patients reported taking on most of the responsibility of their health including booking appointments, and taking their medication. However, the proportion of patients who wanted their parents at their appointments equaled those that did not. Finally, patients reported the following areas of their life their health has negatively impacted; 1) School, 2) Social interactions with family and friends, and 3) Work.

Conclusion

As seen in other diseases, AYA patients with non-malignant hematological conditions have concerns about transitioning to adult care. Young adults have varying degrees of interest and abilities regarding self-care, and are particularly vulnerable to the impact of health issues. Several factors need to be considered when caring for this unique population, that if addressed can improve the transition experience.

Trends and relevance in the bladder and bowel dysfunction literature: PlumX metrics contrasted with fragility indicators

INTRODUCTION

The concepts of fragility index (FI) and fragility quotient (FQ) have been previously described. PlumX metrics encompass online "footprints" of research in addition to traditional citations. Herein we explore PlumX metrics against the quality of BBD literature.

OBJECTIVE

To explore altmetrics against the quality of bladder and bowel dysfunction (BBD) literature.

STUDY DESIGN

A literature search was conducted using Pubmed, Medline, Embase for BBD and related terms. A total of 54,045 abstracts were screened, followed by 693 full text reviews and data extraction from 126. Studies were included if they reported on 2 groups being compared, had dichotomous outcomes, and had significant results.

RESULTS

The median FI score was 4 (0-500) and there were 20 studies which had a FI of 0. The FQ had a median of 0.04 (0-0.32). PlumX usage was 263 ± 540, captures were 45 ± 60 and social media attention was 2 ± 2. Overall, 42% of papers were clinical trials (RCTs). When compared to other study designs, we noted a significant difference in PlumX captures (57 ± 72 RCT vs. 35 ± 47 other; p = 0.03). RCTs had higher usage, social media engagement and citations however, the differences were not significant. H-Index had a significant correlation with FI (p = 0.036), however correlations for PlumX usage and captures, while modestly positive (0.04-0.10) for the FI and FQ, were not significant. A comparison of FI and FQ by topic can be reviewed in the Summary Table.

DISCUSSION

When considering the FI and FQ robustness indicators of the BBD literature, we found similarities when compared to other studies. It was reported that overall, the hydronephrosis literature was fragile with many studies requiring only a few events to nullify significance, regardless of the study design. Similarly, in a review of pediatric vesicoureteral reflux (VUR) clinical trials, results were also fragile. When comparing fragility measures to altmetric variables we noted that despite the growing popularity of altmetrics, citation counts, and h-indices remain the traditional measures to monitor research consumption. There has been a reported correlation between manuscript citation counts, author h-index, altmetrics measures in several specialties and across many domains of research including medical sciences, arts, and the humanities, however in the present study only weak correlations were noted.

CONCLUSION

The body of BBD comparative studies is fragile in keeping with other pediatric urology literature populations. Despite fragile results, RCTs generate slightly moreattention as measured by select PlumX metrics. These results suggest the need for including fragility measures in our literature, aiming to focus attention towards more robust articles.

Designing and evaluating a novel mobile application for Helping Babies Breathe skills retention in Uganda: comparative study protocol

INTRODUCTION

Over 600 000 newborns die each year of intrapartum-related events, many of which are preventable in the presence of skilled birth attendants. Helping Babies Breathe (HBB) is a neonatal resuscitation training programme designed for low-resource settings that can reduce both early neonatal mortality and stillbirths. However, as in other similar educational programmes, knowledge and skill retention deteriorate over time. This trend may be counteracted by strategies such as regular simulated exercises. In this study, a mobile application (app) 'HBB Prompt' will be developed to assist providers in retaining HBB knowledge and skills.

METHODS AND ANALYSIS

This is a comparative study in Uganda with two phases: an app development phase and an assessment phase. In the first phase, HBB trainers and providers will explore barriers and facilitators to enhance learning and maintenance of HBB skills and knowledge through focus group discussions (FGDs). The FGDs are designed with a human factors perspective, enabling collection of relevant data for the prototype version of HBB Prompt. The app will then undergo usability and feasibility testing through FGDs and simulations. In the second phase, a minimum of 10 healthcare workers from two district hospitals will receive HBB training. Only the intervention hospital will have access to HBB Prompt. All participants will be asked to practise HBB skills every shift and record this in a logbook. In the intervention site, app usage data will also be collected. The primary outcome will be comparing skills retention 12 months after training, as determined by Objective Structured Clinical Examination B scores.

ETHICS AND DISSEMINATION

This study received ethics approval from The Hospital for Sick Children and Mbarara University of Science and Technology. The authors plan to publish all relevant findings from this study in peer-reviewed journals.

TRIAL REGISTRATION NUMBER

NCT03577054.

DEVELOPMENT OF A STANDARDIZED APPROACH FOR THE ASSESSMENT OF BOWEL AND BLADDER DYSFUNCTION IN COMMUNITY PAEDIATRICS

BACKGROUND

Bowel and bladder dysfunction (BBD) is a common yet underdiagnosed paediatric condition that describes a constellation of lower urinary tract symptoms (LUTS) associated with constipation and/or encopresis. Many children with BBD have co-morbid neuropsychiatric symptoms (e.g., inattention, anxiety) and psychosocial stressors. Thus, clinical assessment of behavioural symptoms and social risk factors in this population is essential. However, there is no standardized approach for a comprehensive assessment of BBD.

OBJECTIVES

We aim to develop and evaluate physician and parent perceptions with 1) a standardized BBD history and physical intake form for physicians, and 2) a parent-reported intake form.

DESIGN/METHODS

From June to Oct 2017, a quality improvement study was conducted in the BBD network, an existing paediatric collaborative initiative consisting of 7 community sites with support of the paediatric urology division in a tertiary hospital. Based on literature review and expert opinions, a standardized intake form was developed for BBD assessment with targeted questions for LUTS, constipation, behavioural, dietary, and psychosocial history, along with a physical exam checklist for neurological red flags. Further, a shorter parent-reported intake questionnaire was developed to clarify patterns of dysfunctional voiding symptoms, dietary recall and stool history. Both forms underwent usability testing and iterative refinement. Prior to clinic, families of children referred for BBD were mailed an intake package for completion. During the clinic, physicians were asked to use the standardized intake form for new referrals. Afterwards, both physicians and parents were given anonymous surveys to evaluate their perceptions of the intake process.

RESULTS

A total of 8 physicians and 20 parents responded, with 60% of patients being between ages 4–10 and 55% male. Physicians found the standardized intake form to be a useful guide that reminded them to ask about specific urinary symptoms (88% of the time), constipation (75%), and psychosocial history (76%). The majority of physicians (75%) agreed they would use the intake form again and recommended its implementation. Further, parents responded positively by agreeing that the intake package was easy to complete (65%), felt included in care decisions (95%), and had questions answered appropriately (100%).

CONCLUSION

In assessment of BBD, a standardized intake form can help guide physicians to efficiently gather a comprehensive history, rule out red flags, and screen for psychosocial risk factors. With refinements, it can potentially help create a common clinical experience and empower more community paediatricians to manage BBD in the future.

Supplementary data: A critical review of recent clinical practice guidelines for pediatric urinary tract infection

N/A

A critical review of recent clinical practice guidelines for pediatric urinary tract infection

INTRODUCTION

Concerns regarding the quality, credibility, and applicability of recently published pediatric urinary tract infection (UTI) clinical practice guidelines have been raised due to the inconsistencies of recommendations between them. We aimed to determine the quality of the recent clinical practice guidelines on pediatric UTI by using the Appraisal of Guidelines Research and Evaluation (AGREE II) instrument, and summarize the standard of care in diagnosis and management of pediatric UTI from the top three clinical practice guidelines.

METHODS

A systematic literature search was performed on medical literature electronic databases and international guideline repository websites. English language-based clinical practice guidelines from 2007-2016 endorsed by any international society or government organization providing recommendations for the management of pediatric UTI were considered. Eligible clinical practice guidelines were independently appraised by six reviewers using the AGREE II tool. Clinical practice guidelines were assessed for standardized domains and summarized for overall quality. Inter-rater reliability was assessed using inter-class coefficient (ICC).

RESULTS

Thirteen clinical practice guidelines were critically reviewed. The Spanish clinical practice guidelines, American Academy of Pediatrics, and National Institute for Health and Clinical Excellence clinical practice guidelines consistently scored high on all AGREE domains (total averaged domain scores 90, 88, and 88, respectively). Among the six reviewers, there was a high degree of inter-rater reliability (average measure ICC 0.938; p<0.0001). There is reasonable consensus among the top three clinical practice guidelines in their major recommendations.

CONCLUSIONS

The clinical practice guidelines from Spain, American Academy of Pediatrics, and National Institute for Health and Clinical Excellence, with their major recommendations being similar, have scored highly on the AGREE II indicators of quality for the clinical practice guidelines development process.

Paediatric-appropriate facilities in emergency departments of community hospitals in Ontario: A cross-sectional study

BACKGROUND

We assessed whether the paediatric-appropriate facilities were available at Emergency Departments (ED) in community hospitals in a Canadian province.

METHODS

We conducted a cross-sectional survey of EDs in community hospitals in Ontario, Canada that had inpatient paediatric facilities and a neonatal intensive care unit. Key informants were ED chiefs, clinical educators, or managers. The survey included questions about paediatric facilities related to environment, triage, training, and staff in EDs.

RESULTS

Of 52 hospitals, 69% (n=36) responded to our survey. Of them, 14% EDs (n=5) had some separated spaces available for paediatric patients. About 53% (n=19) of EDs lacked children activities, e.g., toys. Only 11% (n=4) EDs were using paediatric triage scales and 42% (n=15) had a designated paediatric resuscitation bay. Only half of the ED (n=18) required from their staff to update paediatric life support training. Only 31% (n=11) had a designated liaison paediatrician for the ED. Paediatric social worker was present in only 8% (n=3) of EDs in community hospitals.

CONCLUSION

Most of the Ontario community hospital EDs included in this survey had inadequate facilities for paediatric patients such as specific waiting and treatment areas.

endoscope-i: an innovation in mobile endoscopic technology transforming the delivery of patient care in otolaryngology

INTRODUCTION

Digital and mobile device technology in healthcare is a growing market. The introduction of the endoscope-i, the world's first endoscopic mobile imaging system, allows the acquisition of high definition images of the ear, nose and throat (ENT). The system combines the e-i Pro camera app with a bespoke engineered endoscope-i adaptor which fits securely onto the iPhone or iPod touch. Endoscopic examination forms a salient aspect of the ENT work-up. The endoscope-i therefore provides a mobile and compact alternative to the existing bulky endoscopic systems currently in use which often restrict the clinician to the clinic setting. Areas covered: This article gives a detailed overview of the endoscope-i system together with its applications. A review and comparison of alternative devices on the market offering smartphone adapted endoscopic viewing systems is also presented. Expert commentary: The endoscope-i fulfils unmet needs by providing a compact, highly portable, simple to use endoscopic viewing system which is cost-effective and which makes use of smartphone technology most clinicians have in their pocket. The system allows real-time feedback to the patient and has the potential to transform the way that healthcare is delivered in ENT as well as having applications further afield.

Documenting the decision-making process for initiation of pharmacological VTE prophylaxis in patients admitted to an adult psychiatry ward background

Background

Venous thromboembolism (VTE) is a condition that causes a blood clot to form within the venous blood system. If this blood clot forms in the peripheral venous system, it can cause symptoms such as calf pain and swelling. If this clot becomes dislodged, it may travel through the vessels into the pulmonary artery which can have much more severe consequences.

Objectives

There has been a great deal of effort in recent years to increase the percentage of in-patients receiving a VTE assessment; and for those patients to receive appropriate VTE prophylaxis. VTE is a significant cause of inpatient deaths. This audit aims to compare current working practice to local standards and identify learning points.

Method

VTE assessment data were collected from two acute psychiatric in-patient wards within a specified, random date range in 2016. Data was collected by checking paper admission documentation. NICE guidelines also state that all patients should be assessed for VTE on admission, with a standard of 100%.

Results

Overall, 6.25% of general adult psychiatry patients had a VTE assessment done within 24 hours of admission.

Conclusion

This audit shows that the necessary standards are not met. Importance of these assessments will be communicated during induction programmes for all staff and the results of this audit communicated to current staff on all in-patient psychiatry wards.

Disclosure of interest

The authors have not supplied their declaration of competing interest.

VTE and physical health assessment upon admission to acute functional and organic psychiatric in-patient wards: An audit

Introduction

Venous thromboembolism (VTE) is a condition that causes a blood clot to form within the venous blood system. If this blood clot forms in the peripheral venous system it can cause symptoms such as calf pain and swelling. If this clot becomes dislodged, it may travel through the vessels into the pulmonary artery which can have much more severe consequences.

Objectives

There has been a great deal of effort in recent years to increase the percentage of in-patients receiving a VTE assessment; and for those patients to receive appropriate VTE prophylaxis. VTE is a significant cause of inpatient deaths. This audit aims to compare current working practice to local standards and identify learning points.

Methods

VTE and physical health assessment data was collected by checking electronic admission summaries from three acute psychiatric in-patient wards on a random date in 2016. The local pathway for the management of physical health and wellbeing states that the VTE assessment and Physical Health Assessment should be completed within 6 hours of admission. NICE guidelines also state that all patients should be assessed on admission, with a standard of 100%.

Results

60% of patients had a VTE assessment and 54% of patients had a physical health assessment done within 6 hours of admission.

Conclusions

This audit shows that the necessary standards are not met. Importance of these assessments has been communicated during induction programmes for all staff.

Disclosure of interest

The authors have not supplied their declaration of competing interest.

Family fIRST, an Interactive Risk Screening Tool for Families in a School-Based Pediatric Clinic

The purpose of this study was to create a tablet-based, social history screening tool called Family fIRST and evaluate its feasibility and usability in a school-based medical clinic. A mixed methods study design was used to examine quantitative and qualitative outcomes of a survey and semi-structured interview completed by families and physicians. The majority (87%) found the survey easy to understand. Themes for improvement included more free-form space and increased sensitivity around question wording. Clinic physicians felt Family fIRST increased discussion around social history and suggested the tool should help link to suggested resources. Demographic results showed that 12 of 29 (43%) parents had income less than $15 000 and 19 of 29 (65%) were unemployed. Family fIRST was a well-received and feasible tool to implement at the school-based medical clinic. Preliminary results show that families attending the clinic have increased prevalence of negative determinants of health; social history should therefore represent a key area of focus at the medical visit in order to optimize clinic support of families.

Imaging central veins in brain lesions with 3-T T2*-weighted magnetic resonance imaging differentiates multiple sclerosis from microangiopathic brain lesions

Background:

White matter lesions are frequently detected using brain magnetic resonance imaging (MRI) performed for various indications. Most are microangiopathic, but demyelination, including multiple sclerosis (MS), is an important cause; conventional MRI cannot always distinguish between these pathologies. The proportion of lesions with a central vein on 7-T T2*-weighted MRI prospectively distinguishes demyelination from microangiopathic lesions.

Objective:

To test whether 3-T T2*-weighted MRI can differentiate MS from microangiopathic brain lesions.

Methods:

A total of 40 patients were studied. Initially, a test cohort of 10 patients with MS and 10 patients with microangiopathic white matter lesions underwent 3-T T2*-weighted brain MRI. Anonymised scans were analysed blind to clinical data, and simple diagnostic rules were devised. These rules were applied to a validation cohort of 20 patients (13 with MS and 7 with microangiopathic lesions) by a blinded observer.

Results:

Within the test cohort, all patients with MS had central veins visible in >45% of brain lesions, while the rest had central veins visible in <45% of lesions. By applying diagnostic rules to the validation cohort, all remaining patients were correctly categorised.

Conclusion:

3-T T2*-weighted brain MRI distinguishes perivenous MS lesions from microangiopathic lesions. Clinical application of this technique could supplement existing diagnostic algorithms.

Are some children with empyema at risk for treatment failure with fibrinolytics? A multicenter cohort study

BACKGROUND

Guidelines recommend that children with empyema be treated initially with chest tube insertion and intrapleural fibrinolytics. Some patients have poor outcomes with this approach, and it is unclear which factors are associated with treatment failure.

METHODS

Possible risk factors were identified through a review of the literature. Treatment failure was defined as need for repeat pleural drainage and/or total length of stay greater than 2weeks.

RESULTS

We retrospectively identified 314 children with empyema treated with fibrinolytics at The Hospital for Sick Children (2000-2013, n=195), Children's Hospital, London Health Sciences Centre (2009-2013, n=39), and McMaster Children's Hospital (2007-2014, n=80). Median length of stay was 11days (range 5-69days). Thirteen percent of children required repeat drainage procedures, and 34% experienced treatment failure. There were no deaths. White blood cell count, erythrocyte sedimentation rate, C-reactive protein, albumin, urea to creatinine ratio, and signs of necrosis on initial chest x-ray were not associated with treatment failure. Multivariable logistic regression demonstrated increased risk with positive blood culture (odds ratio=2.7), immediate admission to intensive care (odds ratio=2.6), and absence of complex septations on baseline ultrasound (odds ratio=2.1). Male gender and platelet count were associated with treatment failure in the univariate analysis but not in the multivariable model.

CONCLUSIONS

Predicting which children with empyema are at risk for treatment failure with fibrinolytics remains challenging. Risk factors include positive blood culture, immediate admission to intensive care, and absence of complex septations on ultrasound. Routine blood work and inflammatory markers have little prognostic value.

PARANEOPLASTIC NMO AND REVIEW OF MRI FINDINGS IN 18 NMO PATIENTS

A 79-year-old lady was admitted with rapid onset weakness in both legs with a mid-throacic sensory level. She had a preceding history of viral upper respiratory infection. She was recently treated for breast cancer 12 months' previously. Within 24 hours she developed complete paraplegia and the MRI scan revealed extensive T2W high signal changes throughout the spinal cord with discrete contrast enhancement and expansion of the cord. CSF showed 7 mononuclear cells with low CSF glucose (vs serum) and high CSF protein. Investigations revealed positive aquaporin-4 antibodies and she rapidly improved after a course of intravenous steroids followed by oral steroid taper. Extensive screen for an underlying malignancy was negative. Given the temporal relationship with cancer, a diagnosis of possible paraneoplastic syndrome was made as per established criteria (Graus et al. 2004).

We took this opportunity to review the MRI findings in 18 of our recent NMO patient cohort (15 aquaporin-4 antibody positive, 1 anti-MOG positive and 2 seronegative). We compared this against the established radiological criteria (Miller DH et al, 2008) for NMO.

We discuss the possibility of NMO being a rare paraneoplastic phenomenon and review the radiological findings in our cohort of NMO patients against established criteria.

Technology-mediated interventions for enhancing medication adherence

BACKGROUND

Despite effective therapies for many conditions, patients find it difficult to adhere to prescribed treatments. Technology-mediated interventions (TMIs) are increasingly being used with the hope of improving adherence.

OBJECTIVE

To assess the effects of TMI, intended to enhance patient adherence to prescribed medications, on both medication adherence and clinical outcomes.

METHODS

A secondary in-depth analysis was conducted of the subset of studies that utilized technology in at least one component of the intervention from an updated Cochrane review on all interventions for enhancing medication adherence. We included studies that clearly described an information and communication technology or medical device as the sole or major component of the adherence intervention.

RESULTS

Thirty-eight studies were eligible for in-depth review. Only seven had a low risk of bias for study design features, primary adherence, and clinical outcomes. Eighteen studies used a TMI for education and/or counseling, 11 studies used a TMI for self-monitoring and/or feedback, and nine studies used electronic reminders. Studies used a variety of TMIs, with telephone the most common technology in use. Studies targeted a wide distribution of diseases and used a variety of adherence and clinical outcome measures. A minority targeted children and adolescents. Fourteen studies reported significant effects in both adherence and clinical outcome measures.

CONCLUSIONS

This review provides evidence for the inconsistent effectiveness of TMI for medication adherence and clinical outcomes. These results must be interpreted with caution due to a lack of high-quality studies.

Interventions for enhancing medication adherence

BACKGROUND

People who are prescribed self administered medications typically take only about half their prescribed doses. Efforts to assist patients with adherence to medications might improve the benefits of prescribed medications.

OBJECTIVES

The primary objective of this review is to assess the effects of interventions intended to enhance patient adherence to prescribed medications for medical conditions, on both medication adherence and clinical outcomes.

SEARCH METHODS

We updated searches of The Cochrane Library, including CENTRAL (via http://onlinelibrary.wiley.com/cochranelibrary/search/), MEDLINE, EMBASE, PsycINFO (all via Ovid), CINAHL (via EBSCO), and Sociological Abstracts (via ProQuest) on 11 January 2013 with no language restriction. We also reviewed bibliographies in articles on patient adherence, and contacted authors of relevant original and review articles.

SELECTION CRITERIA

We included unconfounded RCTs of interventions to improve adherence with prescribed medications, measuring both medication adherence and clinical outcome, with at least 80% follow-up of each group studied and, for long-term treatments, at least six months follow-up for studies with positive findings at earlier time points.

DATA COLLECTION AND ANALYSIS

Two review authors independently extracted all data and a third author resolved disagreements. The studies differed widely according to medical condition, patient population, intervention, measures of adherence, and clinical outcomes. Pooling results according to one of these characteristics still leaves highly heterogeneous groups, and we could not justify meta-analysis. Instead, we conducted a qualitative analysis with a focus on the RCTs with the lowest risk of bias for study design and the primary clinical outcome.

MAIN RESULTS

The present update included 109 new RCTs published since the previous update in January 2007, bringing the total number of RCTs to 182; we found five RCTs from the previous update to be ineligible and excluded them. Studies were heterogeneous for patients, medical problems, treatment regimens, adherence interventions, and adherence and clinical outcome measurements, and most had high risk of bias. The main changes in comparison with the previous update include that we now: 1) report a lack of convincing evidence also specifically among the studies with the lowest risk of bias; 2) do not try to classify studies according to intervention type any more, due to the large heterogeneity; 3) make our database available for collaboration on sub-analyses, in acknowledgement of the need to make collective advancement in this difficult field of research. Of all 182 RCTs, 17 had the lowest risk of bias for study design features and their primary clinical outcome, 11 from the present update and six from the previous update. The RCTs at lowest risk of bias generally involved complex interventions with multiple components, trying to overcome barriers to adherence by means of tailored ongoing support from allied health professionals such as pharmacists, who often delivered intense education, counseling (including motivational interviewing or cognitive behavioral therapy by professionals) or daily treatment support (or both), and sometimes additional support from family or peers. Only five of these RCTs reported improvements in both adherence and clinical outcomes, and no common intervention characteristics were apparent. Even the most effective interventions did not lead to large improvements in adherence or clinical outcomes.

AUTHORS' CONCLUSIONS

Across the body of evidence, effects were inconsistent from study to study, and only a minority of lowest risk of bias RCTs improved both adherence and clinical outcomes. Current methods of improving medication adherence for chronic health problems are mostly complex and not very effective, so that the full benefits of treatment cannot be realized. The research in this field needs advances, including improved design of feasible long-term interventions, objective adherence measures, and sufficient study power to detect improvements in patient-important clinical outcomes. By making our comprehensive database available for sharing we hope to contribute to achieving these advances.