1
|
O'Hearn K, Menon K, Weiler HA, Amrein K, Fergusson D, Gunz A, Bustos R, Campos R, Catalan V, Roedl S, Tsampalieros A, Barrowman N, Geier P, Henderson M, Khamessan A, Lawson ML, McIntyre L, Redpath S, Jones G, Kaufmann M, McNally D. A phase II dose evaluation pilot feasibility randomized controlled trial of cholecalciferol in critically ill children with vitamin D deficiency (VITdAL-PICU study). BMC Pediatr 2023; 23:397. [PMID: 37580663 PMCID: PMC10424361 DOI: 10.1186/s12887-023-04205-9] [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] [Received: 03/27/2023] [Accepted: 07/24/2023] [Indexed: 08/16/2023] Open
Abstract
BACKGROUND Vitamin D deficiency (VDD) is highly prevalent in the pediatric intensive care unit (ICU) and associated with worse clinical course. Trials in adult ICU demonstrate rapid restoration of vitamin D status using an enteral loading dose is safe and may improve outcomes. There have been no published trials of rapid normalization of VDD in the pediatric ICU. METHODS We conducted a multicenter placebo-controlled phase II pilot feasibility randomized clinical trial from 2016 to 2017. We randomized 67 critically ill children with VDD from ICUs in Canada, Chile and Austria using a 2:1 randomization ratio to receive a loading dose of enteral cholecalciferol (10,000 IU/kg, maximum of 400,000 IU) or placebo. Participants, care givers, and outcomes assessors were blinded. The primary objective was to determine whether the loading dose normalized vitamin D status (25(OH)D > 75 nmol/L). Secondary objectives were to evaluate for adverse events and assess the feasibility of a phase III trial. RESULTS Of 67 randomized participants, one was withdrawn and seven received more than one dose of cholecalciferol before the protocol was amended to a single loading dose, leaving 59 participants in the primary analyses (40 treatment, 19 placebo). Thirty-one/38 (81.6%) participants in the treatment arm achieved a plasma 25(OH)D concentration > 75 nmol/L versus 1/18 (5.6%) the placebo arm. The mean 25(OH)D concentration in the treatment arm was 125.9 nmol/L (SD 63.4). There was no evidence of vitamin D toxicity and no major drug or safety protocol violations. The accrual rate was 3.4 patients/month, supporting feasibility of a larger trial. A day 7 blood sample was collected for 84% of patients. A survey administered to 40 participating families showed that health-related quality of life (HRQL) was the most important outcome for families for the main trial (30, 75%). CONCLUSIONS A single 10,000 IU/kg dose can rapidly and safely normalize plasma 25(OH)D concentrations in critically ill children with VDD, but with significant variability in 25(OH)D concentrations. We established that a phase III multicentre trial is feasible. Using an outcome collected after hospital discharge (HRQL) will require strategies to minimize loss-to-follow-up. TRIAL REGISTRATION CLINICALTRIALS gov NCT02452762 Registered 25/05/2015.
Collapse
Affiliation(s)
- Katie O'Hearn
- Research Institute, Children's Hospital of Eastern Ontario, 401 Smyth Road, Ottawa, ON, K1H 8L1, Canada
| | - Kusum Menon
- Research Institute, Children's Hospital of Eastern Ontario, 401 Smyth Road, Ottawa, ON, K1H 8L1, Canada
- Department of Pediatrics, Faculty of Medicine, University of Ottawa, Children's Hospital of Eastern Ontario, Ottawa, Canada
| | - Hope A Weiler
- School of Human Nutrition, Faculty of Agricultural and Environmental Sciences, McGill University, Montreal, Canada
| | - Karin Amrein
- Division of Endocrinology and Diabetology, Department of Internal Medicine, Medical University of Graz, Graz, Austria
| | - Dean Fergusson
- Faculty of Medicine, University of Ottawa, Ottawa, Canada
| | - Anna Gunz
- Department of Paediatrics, Schulich School of Medicine & Dentistry, Western University, London, ON, N6A 5W9, Canada
- Child Health Research Institute, London, ON, N6A 5W9, Canada
| | - Raul Bustos
- Clínica Sanatorio Alemán, Unidad de Cuidados Intensivos Pediátricos, Concepción, Chile
- Facultad de Medicine Y Ciencia, UCI Pediátrica Hospital Guillermo Grant Benavente Concepción, Universidad San Sebastián, Concepción, Chile
| | - Roberto Campos
- Clínica Sanatorio Alemán, Unidad de Cuidados Intensivos Pediátricos, Concepción, Chile
| | - Valentina Catalan
- Clínica Sanatorio Alemán, Unidad de Cuidados Intensivos Pediátricos, Concepción, Chile
| | - Siegfried Roedl
- Department of Paediatrics and Adolescent Medicine, Joint Facilities, Medical University of Graz, Graz, Austria
| | - Anne Tsampalieros
- Clinical Research Unit, Children's Hospital of Eastern Ontario, 401 Smyth Road, Ottawa, ON, K1H 8L1, Canada
| | - Nick Barrowman
- Clinical Research Unit, Children's Hospital of Eastern Ontario, 401 Smyth Road, Ottawa, ON, K1H 8L1, Canada
| | - Pavel Geier
- Department of Pediatrics, Faculty of Medicine, University of Ottawa, Children's Hospital of Eastern Ontario, Ottawa, Canada
| | - Matthew Henderson
- Research Institute, Children's Hospital of Eastern Ontario, 401 Smyth Road, Ottawa, ON, K1H 8L1, Canada
- Department of Pathology and Laboratory Medicine, Faculty of Medicine, University of Ottawa, Children's Hospital of Eastern Ontario, Newborn Screening Ontario, Ottawa, Canada
| | - Ali Khamessan
- Euro-Pharm International Canada Inc, Montreal, Canada
| | - Margaret L Lawson
- Research Institute, Children's Hospital of Eastern Ontario, 401 Smyth Road, Ottawa, ON, K1H 8L1, Canada
- Department of Pediatrics, Faculty of Medicine, University of Ottawa, Children's Hospital of Eastern Ontario, Ottawa, Canada
- Division of Endocrinology, Department of Pediatrics, Children's Hospital of Eastern Ontario, Ottawa, Canada
| | - Lauralyn McIntyre
- Department of Medicine (Division of Critical Care), Ottawa Hospital Research Institute (OHRI), University of Ottawa, Ottawa, Canada
| | - Stephanie Redpath
- Department of Pediatrics, Faculty of Medicine, University of Ottawa, Children's Hospital of Eastern Ontario, Ottawa, Canada
| | - Glenville Jones
- Department of Biomedical and Molecular Sciences, Queen's University, Kingston, Canada
| | - Martin Kaufmann
- Department of Biomedical and Molecular Sciences, Queen's University, Kingston, Canada
| | - Dayre McNally
- Research Institute, Children's Hospital of Eastern Ontario, 401 Smyth Road, Ottawa, ON, K1H 8L1, Canada.
- Department of Pediatrics, Faculty of Medicine, University of Ottawa, Children's Hospital of Eastern Ontario, Ottawa, Canada.
| |
Collapse
|
2
|
Wilk P, Gunz A, Maltby A, Ravichakaravarthy T, Clemens KK, Lavigne É, Lim R, Vicedo-Cabrera AM. Extreme heat and paediatric emergency department visits in Southwestern Ontario. Paediatr Child Health 2020; 26:305-309. [PMID: 34336059 DOI: 10.1093/pch/pxaa096] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2020] [Accepted: 07/30/2020] [Indexed: 01/12/2023] Open
Abstract
Objective The risk of adverse health events is expected to increase with hotter temperatures, particularly among the most vulnerable groups such as elderly persons and children. The objective of this study was to assess the association between extreme heat and daily emergency department visits among children (0 to 17 years) in Southwestern Ontario. Methods We examined the average maximum temperature, relative humidity, and daily paediatric emergency department visits in June through August of 2002 to 2019. We reviewed emergency department visits from two academic hospitals. Daily meteorological data from the local weather station were obtained from Environment and Climate Change Canada. Results Extreme heat, defined as the 99th percentile of the maximum temperature distribution, occurred at 33.1°C and was associated with an overall 22% increase in emergency department visits, compared to the reference temperature of 21°C. This association was mostly found between the second and fifth day after the exposure, suggesting a slightly delayed effect. The results of the sub-group analysis indicate that the risk of an emergency department visit due to infectious disease increases by 35% and the most pronounced association was noted in children aged 1 to 12 years. Conclusions Extreme heat is associated with an increased incidence of emergency department visits in children. As temperatures continue to increase, strategies to mitigate heat-related health risks among children should be developed.
Collapse
Affiliation(s)
- Piotr Wilk
- Department of Epidemiology and Biostatistics, Western University, London, Ontario.,Department of Paediatrics, Western University, London, Ontario.,Child Health Research Institute, London, Ontario.,Lawson Health Research Institute, London, Ontario
| | - Anna Gunz
- Department of Paediatrics, Western University, London, Ontario.,Child Health Research Institute, London, Ontario.,Division of Paediatric Critical Care, Children's Hospital, London Health Sciences Center, London, Ontario
| | - Alana Maltby
- Department of Epidemiology and Biostatistics, Western University, London, Ontario
| | | | - Kristin K Clemens
- Department of Epidemiology and Biostatistics, Western University, London, Ontario.,Lawson Health Research Institute, London, Ontario.,Department of Medicine, Western University, London, Ontario.,ICES, London, Ontario.,St. Joseph's Health Care, London, Ontario
| | - Éric Lavigne
- Air Health Science Division, Health Canada, Ottawa, Ontario.,School of Epidemiology and Public Health, Faculty of Medicine, University of Ottawa, Ottawa, Ontario
| | - Rodrick Lim
- Department of Paediatrics, Western University, London, Ontario.,Child Health Research Institute, London, Ontario.,Division of Paediatric Emergency Medicine, Children's Hospital, London Health Sciences Center, London, Ontario
| | - Ana Maria Vicedo-Cabrera
- Institute of Social and Preventive Medicine, University of Bern, Bern, Switzerland.,Oeschger Center for Climate Change Research, University of Bern, Bern, Switzerland
| |
Collapse
|
3
|
Ali A, Miller M, Cameron S, Gunz A. 1 Paediatric Transport Safety Collaborative (PTSIC): Critical Events with Family Presence During Paediatric Critical Care Transport. Paediatr Child Health 2020. [DOI: 10.1093/pch/pxaa068.000] [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] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Abstract
Background
Health care of children in Canada is regionalized; thus, critically ill paediatric patients require transfer to a tertiary care centre for definitive medical and surgical management. There are risks inherent to transporting critically ill patients, and there is a body of literature looking to mitigate risk, which includes tracking and benchmarking quality metrics. One accepted metric is family accompaniment of a child during transport, with some studies suggesting that family accompaniment could compromise care. Currently, there has been no research that examines patient safety and outcomes during paediatric critical care transport with family presence.
Objectives
The primary objective of this study was to compare the rate of critical events (CEs) during the transport of paediatric patients by a specialized paediatric critical care transport team on transports with parental/caregiver accompaniment (P/CA) to those without P/CA. Secondary objectives included whether peak heart rate (HR), systolic blood pressure (SBP), and clinically relevant patient outcomes varied between groups.
Design/Methods
We conducted a retrospective cohort study of all patients (<18 years old) who were admitted to a Paediatric Critical Care Unit and transported by the local neonatal paediatric transport team between April 1st, 2018 and June 1st, 2019, inclusive. The primary outcome was CE occurrence using the composite definition of CE that was previously identified and defined by a national consensus process, which included patient-, transport provider-, laboratory- and system/vehicle- related safety factors. Secondary outcomes included peak and trough HR/SBP, and clinically relevant outcomes (including length of stay, mechanical ventilation free days, and severity of illness and organ dysfunction scores).
Results
There were a total of 178 transports eligible for analysis, and of those, 55 were with P/CA and 123 were without P/CA. The occurrence of CE was not significantly different between transports with and without P/CA (66% vs. 65%, respectively). Similarly, patient HR, SBP, and all measured clinical patient outcomes did not vary significantly between groups.
Conclusion
This study is the first to objectively measure CEs and relate them to patient clinical outcomes with regard to presence of P/CA during paediatric critical care transport. There was no identified increased risk to the patient or crew if parents/caregivers accompanied their child during transport. Areas of future study include whether parental/caregiver presence during transport affects patient anxiety and well-being.
Collapse
Affiliation(s)
- Aaisham Ali
- Department of Paediatrics, Schulich School of Medicine & Dentistry, Western University
| | - Michael Miller
- Department of Paediatrics, Schulich School of Medicine & Dentistry, Western University
- Children’s Health Research Institute, London, Ontario
| | - Saoirse Cameron
- Department of Paediatrics, Schulich School of Medicine & Dentistry, Western University
| | - Anna Gunz
- Department of Paediatrics, Schulich School of Medicine & Dentistry, Western University
- Children’s Health Research Institute, London, Ontario
| |
Collapse
|
4
|
Van Deven T, Sukhera J, Gunz A, Tithecott G. Social Medicine, New Medicine? A curricular integration driving deeper learning with the social drivers of patient care. MedEdPublish 2016. [DOI: 10.15694/mep.2016.000155] [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: 11/06/2022] Open
Abstract
This article was migrated. The article was marked as recommended. In response to a curricular vision of improved social accountability, our Doctor of Medicine program launched a year-long integrated Social Medicine course designed and implemented for Year 1 medical school students. Our school is a moderate sized medical school serving a region of close to 2 M people in central Canada. The Schulich School of Medicine & Dentistry Doctor of Medicine Program at Western University, London, Ontario Canada, is grounded in a four-year curriculum, each year comprised of up to 171 students with a clinical clerkship in Year 3. Our curriculum is delivered in a distributed fashion between two campuses approximately 200 km apart: London (133) and Windsor (38) learners.The vision of our leadership and learner partners was to provide students with an opportunity to concentrate early in their career on the impact of social, cultural and economic forces on medicine and patient care. Under the umbrella of this new Social Medicine course, we incorporated previous courses in population health, epidemiology, ethics and service learning to provide an exposure to cultural and societal roots; social inequalities; factors impacting treatment outcomes; ethical challenges and experiential community learning opportunities. This article, based upon our Short Communication, "Social Medicine, New Medicine? Redefining Social Medicine for Year 1 medical students", presented at AMEE in Barcelona, 2016, will discuss the origins of our course design as well as the rationale, objectives and caveats of this particular course.
Collapse
|
7
|
Schoedon G, Goldenberger D, Forrer R, Gunz A, Dutly F, Höchli M, Altwegg M, Schaffner A. Deactivation of macrophages with interleukin-4 is the key to the isolation of Tropheryma whippelii. J Infect Dis 1997; 176:672-7. [PMID: 9291314 DOI: 10.1086/514089] [Citation(s) in RCA: 117] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Abstract
Whipple's disease is a systemic illness caused by a specific agent. Despite recognition of bacteria in lesions, efforts to isolate the causative agent remained futile. A novel strategy was devised to culture Whipple bacilli in deactivated mononuclear phagocytes. Infected tissue was inoculated into human phagocytes deactivated with interleukin (IL)-4, IL-10, and dexamethasone. Within 8-10 days, diastase-resistant periodic acid-Schiff-positive inclusions appeared, corresponding to intact and degenerating bacteria shown to be Tropheryma whippelii by electron microscopy and molecular analyses. T. whippelii was passaged several times in deactivated monocytes and a monoblastic cell line. Time-kinetics growth studies and comparative polymerase chain reaction analysis documented multiplication of T. whippelii in deactivated macrophages. Complementary studies showed that IL-4 rendered phagocytes permissive for T. whippelii, a strong indication that host factors contribute to the pathogenesis of Whipple's disease. The propagation of T. whippelii will permit microbiologic, immunologic, seroepidemiologic, and therapeutic studies of this pathogen.
Collapse
Affiliation(s)
- G Schoedon
- Department of Medicine, University of Zurich Medical School, Switzerland
| | | | | | | | | | | | | | | |
Collapse
|