Migraine or any headaches and white matter hyperintensities and their progression in women and men

BACKGROUND

Cross-sectional and longitudinal studies have been conducted to investigate the association between migraine and any headache and white matter hyperintensities (WMH). However, studies are inconsistent regarding the strength of the association and its clinical significance. The aim of our study was to investigate the association between headache and its subtypes (migraine with aura (MigA+), migraine without aura (MigA-), non-migraine headache (nonMigHA)) and WMH and its course in the population-based 1000BRAINS study using state-of-the-art imaging techniques and migraine classification according to modified international classification of headache disorders.

METHODS

Data from 1062 participants (45% women, 60.9 ± 13.0 years) with ever or never headache (neverHA) and complete quantitative (WMH volume) and qualitative (Fazekas classification) WMH data at first imaging and after 3.7 ± 0.7 years (393 participants) were analyzed. The sex-specific association between headache and its subtypes and WMH volume and its change was evaluated by linear regression, between headache and its subtypes and Fazekas score high vs. low (2-3 vs. 0-1) by log-binomial regression, adjusted for confounders.

RESULTS

The lifetime prevalence of headache was 77.5% (10.5% MigA+, 26.9% MigA-, 40.1% nonMigHA). The median WMH volume was 4005 (IQR: 2454-6880) mm3 in women and 4812 (2842-8445) mm3 in men. Women with any headaches (all headache types combined) had a 1.23 [1.04; 1.45]-fold higher WMH volume than women who reported never having had a headache. There was no indication of higher Fazekas grading or more WMH progression in women with migraine or any headaches. Men with migraine or any headaches did not have more WMH or WMH progression compared to men without migraine or men who never had headache.

CONCLUSIONS

Our study demonstrated no increased occurrence or progression of WMH in participants with mgiraine. But, our results provide some evidence of greater WMH volume in women with headache of any type including migraine. The underlying pathomechanisms and the reasons why this was not shown in men are unclear and require further research.

Whole Blood Cardiac Troponin "Triaging" to Improve Early Detection of Myocardial Injury at a Pediatric Hospital

BACKGROUND

The importance of offering on-site cardiac troponin (cTn) testing at pediatric hospitals may be underappreciated. We developed a rapid rule-in process for myocardial injury at a pediatric hospital experiencing delays in off-site high-sensitivity cardiac troponin T (hs-cTnT) testing.

METHODS

Collect-to-verify turnaround times (TATs) for off-site testing were reviewed. Pre-analytic changes to improve TATs were devised, implemented and evaluated, after which a new analyzer was selected and evaluated for on-site cTn testing. Performance of the new analyzer's assay was compared to the off-site hs-cTnT assay, and post go-live TATs for on-site testing were assessed.

RESULTS

Median collect-to-verify TAT for short turnaround-time (STAT) priority off-site plasma hs-cTnT testing was 104 min, with 35% of orders having a TAT >120 min. Eliminating serum separator tubes and requiring a separate plasma separator tube did not significantly reduce TATs. A QuidelOrtho Triage® MeterPro whole blood cardiac troponin I (cTnI) assay was implemented to "triage" time-critical and STAT priority specimens collected for off-site hs-cTnT testing. Elevated cTnI (≥0.02 µg/L) had a sensitivity of 91% for clear elevations in hs-cTnT (≥53 ng/L) but a 0% sensitivity for modest elevations (5 to 13 ng/L, 14 to 52 ng/L). An interpretive comment was auto-appended to cTnI results indicating that clinicians should wait for the hs-cTnT result if cTnI was normal. Median collect-to-verify TAT for on-site cTnI testing was <50% the TAT for off-site hs-cTnT testing.

CONCLUSIONS

On-site point-of-care whole blood cTn testing can rapidly confirm significant or late-presenting myocardial injury. Combined with simultaneous off-site high-sensitivity cardiac troponin (hs-cTn) testing, this workflow is a viable interim solution for pediatric hospitals without on-site hs-cTn testing.

Clinical Practice Guideline Recommendations in Pediatric Mild Traumatic Brain Injury: A Systematic Review

STUDY OBJECTIVE

Our primary objectives were to identify clinical practice guideline recommendations for children with acute mild traumatic brain injury (mTBI) presenting to an emergency department (ED), appraise their overall quality, and synthesize the quality of evidence and the strength of included recommendations.

METHODS

We searched MEDLINE, EMBASE, Cochrane Central, Web of Science, and medical association websites from January 2012 to May 2023 for clinical practice guidelines with at least 1 recommendation targeting pediatric mTBI populations presenting to the ED within 48 hours of injury for any diagnostic or therapeutic intervention in the acute phase of care (ED and inhospital). Pairs of reviewers independently assessed overall clinical practice guideline quality using the Appraisal of Guidelines Research and Evaluation (AGREE) II tool. The quality of evidence on recommendations was synthesized using a matrix based on the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) Evidence-to-Decision framework.

RESULTS

We included 11 clinical practice guidelines, of which 6 (55%) were rated high quality. These included 101 recommendations, of which 34 (34%) were based on moderate- to high-quality evidence, covering initial assessment, initial diagnostic imaging, monitoring/observation, therapeutic interventions, discharge advice, follow-up, and patient and family support. We did not identify any evidence-based recommendations in high-quality clinical practice guidelines for repeat imaging, neurosurgical consultation, or hospital admission. Lack of strategies and tools to aid implementation and editorial independence were the most common methodological weaknesses.

CONCLUSIONS

We identified 34 recommendations based on moderate- to high-quality evidence that may be considered for implementation in clinical settings. Our review highlights important areas for future research. This review also underlines the importance of providing strategies to facilitate the implementation of clinical practice guideline recommendations for pediatric mTBI.

Clinical Practice Guideline Recommendations For Pediatric Multisystem Trauma Care: A Systematic Review

OBJECTIVE

To systematically review clinical practice guidelines (CPGs) for pediatric multisystem trauma, appraise their quality, synthesize the strength of recommendations and quality of evidence, and identify knowledge gaps.

BACKGROUND

Traumatic injuries are the leading cause of death and disability in children, who require a specific approach to injury care. Difficulties integrating CPG recommendations may cause observed practice and outcome variation in pediatric trauma care.

METHODS

We conducted a systematic review using Medline, Embase, Cochrane Library, Web of Science, ClinicalTrials, and grey literature, from January 2007 to November 2022. We included CPGs targeting pediatric multisystem trauma with recommendations on any acute care diagnostic or therapeutic interventions. Pairs of reviewers independently screened articles, extracted data, and evaluated the quality of CPGs using "Appraisal of Guidelines, Research, and Evaluation II."

RESULTS

We reviewed 19 CPGs, and 11 were considered high quality. Lack of stakeholder engagement and implementation strategies were weaknesses in guideline development. We extracted 64 recommendations: 6 (9%) on trauma readiness and patient transfer, 24 (38%) on resuscitation, 22 (34%) on diagnostic imaging, 3 (5%) on pain management, 6 (9%) on ongoing inpatient care, and 3 (5%) on patient and family support. Forty-two (66%) recommendations were strong or moderate, but only 5 (8%) were based on high-quality evidence. We did not identify recommendations on trauma survey assessment, spinal motion restriction, inpatient rehabilitation, mental health management, or discharge planning.

CONCLUSIONS

We identified 5 recommendations for pediatric multisystem trauma with high-quality evidence. Organizations could improve CPGs by engaging all relevant stakeholders and considering barriers to implementation. There is a need for robust pediatric trauma research, to support recommendations.

Family caregivers' emotional and communication needs in Canadian pediatric emergency departments

OBJECTIVES

To describe the extent to which caregivers' emotional and communication needs were met during pediatric emergency department (PED) visits. Secondary objectives included describing the association of caregiver emotional needs, satisfaction with care, and comfort in caring for their child's illness at the time of discharge with demographic characteristics, caregiver experiences, and ED visit details.

STUDY DESIGN

Electronic surveys with medical record review were deployed at ten Canadian PEDs from October 2018 -March 2020. A convenience sample of families with children <18 years presenting to a PED were enrolled, for one week every three months, for one year per site. Caregivers completed one in-PED survey and a follow-up survey, up to seven days post-visit.

RESULTS

This study recruited 2005 caregivers who self-identified as mothers (74.3%, 1462/1969); mean age was 37.8 years (SD 7.7). 71.7% (1081/1507) of caregivers felt their emotional needs were met. 86.4% (1293/1496) identified communication with the doctor as good/very good and 83.4% (1249/1498) with their child's nurse. Caregiver involvement in their child's care was reported as good/very good 85.6% (1271/1485) of the time. 81.8% (1074/1313) of caregivers felt comfortable in caring for their child at home at the time of discharge. Lower caregiver anxiety scores, caregiver involvement in their child's care, satisfactory updates, and having questions adequately addressed positively impacted caregiver emotional needs and increased caregiver comfort in caring for their child's illness at home.

CONCLUSION

Approximately 30% of caregivers presenting to PEDs have unmet emotional needs, over 15% had unmet communication needs, and 15% felt inadequately involved in their child's care. Family caregiver involvement in care and good communication from PED staff are key elements in improving overall patient experience and satisfaction.

Clinical Practice Guideline Recommendations in Pediatric Orthopaedic Injury: A Systematic Review

BACKGROUND

Lack of adherence to recommendations on pediatric orthopaedic injury care may be driven by lack of knowledge of clinical practice guidelines (CPGs), heterogeneity in recommendations or concerns about their quality. We aimed to identify CPGs for pediatric orthopaedic injury care, appraise their quality, and synthesize the quality of evidence and the strength of associated recommendations.

METHODS

We searched Medline, Embase, Cochrane CENTRAL, Web of Science and websites of clinical organizations. CPGs including at least one recommendation targeting pediatric orthopaedic injury populations on any diagnostic or therapeutic intervention developed in the last 15 years were eligible. Pairs of reviewers independently extracted data and evaluated CPG quality using the Appraisal of Guidelines Research and Evaluation (AGREE) II tool. We synthesized recommendations from high-quality CPGs using a recommendations matrix based on the GRADE Evidence-to-Decision framework.

RESULTS

We included 13 eligible CPGs, of which 7 were rated high quality. Lack of stakeholder involvement and applicability (i.e., implementation strategies) were identified as weaknesses. We extracted 53 recommendations of which 19 were based on moderate or high-quality evidence.

CONCLUSIONS

We provide a synthesis of recommendations from high-quality CPGs that can be used by clinicians to guide treatment decisions. Future CPGs should aim to use a partnership approach with all key stakeholders and provide strategies to facilitate implementation. This study also highlights the need for more rigorous research on pediatric orthopaedic trauma.

LEVEL OF EVIDENCE

Level II-therapeutic study.

Pediatric Moderate and Severe Traumatic Brain Injury: A Systematic Review of Clinical Practice Guideline Recommendations

Traumatic brain injury (TBI) is the leading cause of death and disability in children. Many clinical practice guidelines (CPGs) have addressed pediatric TBI in the last decade but significant variability in the use of these guidelines persists. Here, we systematically review CPGs recommendations for pediatric moderate-to-severe TBI, evaluate the quality of CPGs, synthesize the quality of evidence and strength of included recommendations, and identify knowledge gaps. A systematic search was conducted in MEDLINE®, Embase, Cochrane CENTRAL, Web of Science, and Web sites of organizations publishing recommendations on pediatric injury care. We included CPGs developed in high-income countries from January 2012 to May 2023, with at least one recommendation targeting pediatric (≤ 19 years old) moderate-to-severe TBI populations. The quality of included clinical practice guidelines was assessed using the AGREE II tool. We synthesized evidence on recommendations using a matrix based on the Grading of Recommendations Assessment, Development and Evaluation (GRADE) framework. We identified 15 CPGs of which 9 were rated moderate to high quality using AGREE II. We identified 90 recommendations, of which 40 (45%) were evidence based. Eleven of these were based on moderate to high quality evidence and were graded as moderate or strong by at least one guideline. These included transfer, imaging, intracranial pressure control, and discharge advice. We identified gaps in evidence-based recommendations for red blood cell transfusion, plasma and platelet transfusion, thromboprophylaxis, surgical antimicrobial prophylaxis, early diagnosis of hypopituitarism, and mental health mangement. Many up-to-date CPGs are available, but there is a paucity of evidence to support recommendations, highlighting the urgent need for robust clinical research in this vulnerable population. Our results may be used by clinicians to identify recommendations based on the highest level of evidence, by healthcare administrators to inform guideline implementation in clinical settings, by researchers to identify areas where robust evidence is needed, and by guideline writing groups to inform the updating of existing guidelines or the development of new ones.

Pediatric vs Adult or Mixed Trauma Centers in Children Admitted to Hospitals Following Trauma: A Systematic Review and Meta-Analysis

Importance

Adult trauma centers (ATCs) have been shown to decrease injury mortality and morbidity in major trauma, but a synthesis of evidence for pediatric trauma centers (PTCs) is lacking.

Objective

To assess the effectiveness of PTCs compared with ATCs, combined trauma centers (CTCs), or nondesignated hospitals in reducing mortality and morbidity among children admitted to hospitals following trauma.

Data Sources

MEDLINE, Embase, and Web of Science through March 2023.

Study Selection

Studies comparing PTCs with ATCs, CTCs, or nondesignated hospitals for pediatric trauma populations (aged ≤19 years).

Data Extraction and Synthesis

This systematic review and meta-analysis was performed following the Preferred Reporting Items for Systematic Review and Meta-analysis and Meta-analysis of Observational Studies in Epidemiology guidelines. Pairs of reviewers independently extracted data and evaluated risk of bias using the Risk of Bias in Nonrandomized Studies of Interventions tool. A meta-analysis was conducted if more than 2 studies evaluated the same intervention-comparator-outcome and controlled minimally for age and injury severity. Subgroup analyses were planned for age, injury type and severity, trauma center designation level and verification body, country, and year of conduct. Grading of Recommendations Assessment, Development, and Evaluation (GRADE) was used to assess certainty of evidence.

Main Outcome(s) and Measure(s)

Primary outcomes were mortality, complications, functional status, discharge destination, and quality of life. Secondary outcomes were resource use and processes of care, including computed tomography (CT) and operative management of blunt solid organ injury (SOI).

Results

A total of 56 studies with 286 051 participants were included overall, and 34 were included in the meta-analysis. When compared with ATCs, PTCs were associated with a 41% lower risk of mortality (OR, 0.59; 95% CI, 0.46-0.76), a 52% lower risk of CT use (OR, 0.48; 95% CI, 0.26-0.89) and a 64% lower risk of operative management for blunt SOI (OR, 0.36; 95% CI, 0.23-0.57). The OR for complications was 0.80 (95% CI, 0.41-1.56). There was no association for mortality for older children (OR, 0.71; 95% CI, 0.47-1.06), and the association was closer to the null when PTCs were compared with CTCs (OR, 0.73; 95% CI, 0.53-0.99). Results remained similar for other subgroup analyses. GRADE certainty of evidence was very low for all outcomes.

Conclusions and Relevance

In this systematic review and meta-analysis, results suggested that PTCs were associated with lower odds of mortality, CT use, and operative management for SOI than ATCs for children admitted to hospitals following trauma, but certainty of evidence was very low. Future studies should strive to address selection and confounding biases.

Clinical practice guideline recommendations for pediatric solid organ injury care: A Systematic Review

BACKGROUND

Observed variations in the management of pediatric solid organ injuries (SOIs) may be due to difficulty in finding and integrating recommendations from multiple clinical practice guidelines (CPGs) with heterogeneous methodological approaches. We aimed to systematically review CPG recommendations for pediatric SOIs.

METHODS

We conducted a systematic review of CPGs including at least one recommendation targeting pediatric SOI populations, using Medical Analysis and Retrieval System Online, Excerpta Medica dataBASE, Web of Science, and websites of clinical organizations. Pairs of reviewers independently assessed eligibility, extracted data, and evaluated the quality of CPGs using the Appraisal of Guidelines Research and Evaluation II tool. We synthesized recommendations from moderate to high-quality CPGs using a recommendations matrix based on Grades of Recommendation, Assessment, Development, and Evaluation criteria.

RESULTS

We identified eight CPGs, including three rated moderate or high quality. Methodological weaknesses included lack of stakeholder involvement beyond surgeons, consideration of applicability (e.g., implementation tools), and clarity around the definition of pediatric populations. Five of the 15 recommendations from moderate to high-quality CPGs were based on moderate quality evidence or were rated as strong; these reflected nonoperative management and angioembolization for renal injuries and required length of stay for liver and spleen injuries.

CONCLUSION

We identified 15 recommendations on pediatric SOI management from 3 moderate or high-quality CPGs, but only one third were based on at least moderate-quality evidence or were rated as strong. Our results prompt the following recommendations for future CPG development or updates: (1) include all types of clinicians involved in the care of pediatric SOIs and patient and family representatives in the process, (2) develop clear definitions of the target population, and (3) provide advice and tools to promote implementation. Results also underline the urgent need for more rigorous research to support strong evidence-based recommendations in this population.

LEVEL OF EVIDENCE

Systematic Review/Meta-analysis; Level III.

Factors Influencing Parental Decision-Making Regarding Analgesia for Children with Musculoskeletal Injury-Related Pain: A Qualitative Study

OBJECTIVES

To explore and understand parental decision-making relating to acute pain management for their children presenting to the emergency department.

STUDY DESIGN

This study employed one-on-one semistructured interviews. Parents of children with acute musculoskeletal injuries were recruited from 3 Canadian pediatric emergency departments. Interviews were conducted via telephone from June 2019 to March 2021. Verbatim transcription and thematic analyses occurred concurrently with data collection, supporting data saturation and theory development considerations.

RESULTS

Twenty-seven interviews were completed. Five major themes regarding pain care emerged: (1) my child's comfort is a priority, (2) every situation is unique, (3) opioids only if necessary, (4) considerations when choosing opioids, and (5) pain research is important. Overall, parents were highly comfortable with their assessment of their child's pain. Participants' willingness to use opioid analgesia for their children was primarily dependent on perceptions of injury and pain severity. Opioid-averse and opioid-accepting families had similar considerations when making analgesic decisions but weighed risks and benefits differently.

CONCLUSIONS

Parents assess and manage their children's pain globally and multimodally, with comfort being prioritized. For most parents, the desire to relieve their children's pain outweighed concerns of substance use disorder, misuse, and adverse events when making decisions about opioid analgesia for short-term use. These results can inform evidence-based family-centered approaches to co-decision-making of analgesic plans for children with acute pain.

An evaluation of satisfaction with emergency department care in children and adolescents with mental health concerns

OBJECTIVES

We hypothesized that an association exists between satisfaction with ED mental health care delivery and patient and system characteristics. Primary: To evaluate overall satisfaction with ED mental health care delivery. Secondary: To explore aspects of ED mental health care delivery associated with general satisfaction, and patient and ED visit characteristic associated with total satisfaction scores and reported care experience themes.

METHODS

We enrolled patients < 18 years of age presenting with a mental health concern between February 1, 2020 and January 31, 2021, to two pediatric EDs in Alberta, Canada. Satisfaction data were collected using the Service Satisfaction Scale, a measure of global satisfaction with mental health services. Association of general satisfaction with ED mental health care was evaluated using Pearson's correlation coefficient and variables associated with total satisfaction score was assessed using multivariable regression analyses. Inductive thematic analysis of qualitative feedback identified satisfaction and patient experience themes.

RESULTS

646 participants were enrolled. 71.2% were Caucasian and 56.3% female. Median age was 13 years (IQR 11-15). Parents/caregivers (n = 606) and adolescents (n = 40) were most satisfied with confidentiality and respect in the ED and least satisfied with how ED services helped reduce symptoms and/or problems. General satisfaction was associated with perceived amount of help received in the ED (r = 0.85) and total satisfaction with evaluation by a mental health team member (p = 0.004) and psychiatrist consultation (p = 0.05). Comments demonstrated satisfaction with ED provider attitudes and interpersonal skills and dissatisfaction with access to mental health and addictions care, wait time, and the impact of COVID-19.

CONCLUSIONS

There is a need to improve ED mental health care delivery, with a focus on timely access to ED mental health providers. Access to outpatient/community-based mental health care is needed to complement care received in the ED and to provide continuity of care for youth with mental health concerns.

Cerebral Hemodynamics and Microvasculature Changes in Relation to White Matter Microstructure After Pediatric Mild Traumatic Brain Injury: An A-CAP Pilot Study

Advanced neuroimaging techniques show promise as a biomarker for mild traumatic brain injury (mTBI). However, little research has evaluated cerebral hemodynamics or its relation to white matter microstructure post-mTBI in children. This novel pilot study examined differences in cerebral hemodynamics, as measured using functional near-infrared spectroscopy (fNIRS), and its association with diffusion tensor imaging (DTI) metrics in children with mTBI or mild orthopedic injury (OI) to address these gaps. Children 8.00-16.99 years of age with mTBI (n = 9) or OI (n = 6) were recruited in a pediatric emergency department, where acute injury characteristics were assessed. Participants completed DTI twice, post-acutely (2-33 days) and chronically (3 or 6 months), and fNIRS ∼1 month post-injury. Automated deterministic tractography was used to compute DTI metrics. There was reduced absolute phase globally and coherence in the dorsolateral pre-frontal cortex (DLPFC) after mTBI compared to the OI group. Coherence in the DLPFC and absolute phase globally showed distinct associations with fractional anisotropy in interhemispheric white matter pathways. Two fNIRS metrics (coherence and absolute phase) differentiated mTBI from OI in children. Variability in cerebral hemodynamics related to white matter microstructure. The results provide initial evidence that fNIRS may have utility as a clinical biomarker of pediatric mTBI.

64 A Canadian multicentre survey of family needs when attending the pediatric emergency department

Background

Parents/caregivers strongly influence their child’s experience in the pediatric emergency department (PED). Understanding their needs can improve families’ PED experience and care.

Objectives

To describe caregivers’ perceived emotional, practical, and informational needs in the PED and how well these needs were met

Design/Methods

This descriptive, cross-sectional survey with medical record review was conducted at 10 Canadian PEDs from October 2018 to March 2020, over a 1-week period every season, for a total of 4 weeks per site. Digital surveys available in English or French were completed by caregivers in the PED and 7 days after their visit. Health literacy was evaluated by the Newest Vital Sign tool.

Results

A total of 2005 caregivers participated; mean age was 37.8 (SD 7.7) years, and 74.3% (1462/1969) were mothers. The mean child age was 5.9 (5.1) years and 51.9 % (1040/2003) were male. Caregivers’ main spoken language was mostly English [72.6% (1425/1964)] or French [10.5% (206/1964)]. Over half of caregivers had a university/professional degree [51.0% (997/1956)]; 37.4% (746/1998) had possible/probable limited health literacy. 77.9% (1132/1454) of caregivers reported that their overall care needs were met. 71.7% (1081/1507) of caregivers reported that their emotional needs were met; they reported most emotional support by doctors [(35.6%, 535/1510)] and bedside nurses [(24.2%, 364/1507)]. The median (IQR) length of stay was 3.9 (2.6, 6.1) hours; 36.7% (546/1487) of caregivers felt they waited ‘too long’, and 77.8% (1158/1489) did not know how long they would have to wait. 11.7% of families were dissatisfied with the care updates provided. A safe PED was the top overall identified practical need [(45.1%, 602/1336)]. Internet access was the most important practical need throughout the visit [(28.1%, 378/1345)], while more space was the most reported [(49.8%, 696/1398)] need in the waiting room. The most desired improvements in the PED were better communication of wait times and delays [(41.1%, 745/1812)], shorter wait times [(38.8%, 699/1801)] and faster diagnosis [(24.9%, 449/1803)].

Conclusion

Almost one quarter of Canadian caregivers report that their overall needs were not fully met when attending the PED. Safety during the PED visit was of utmost importance. Nationally, caregivers value shorter wait times, rapid diagnosis, and better communication about perceived delays. Top practical needs included internet access and more waiting room space. Creating innovative waiting systems, better methods to share wait time information, free internet access, and improved physical spaces could better address identified caregiver needs in the PED.

Willingness to participate in a COVID-19 follow-up study and symptoms 1.5 years after infection

Introduction

Data on willingness to participate in population-based long-COVID studies are sparse. We invited all citizens of Essen aged 18-74 years with a positive SARS-CoV-2 PCR test between Mar-Aug 2020 and assessed COVID-related symptoms in responders ∼1.5 years after infection.

Methods

The invited population included 1282 infected citizens (48% women). At the time of testing 64% reported symptoms. We asked responders about past and current symptoms, hospitalization, smoking, sport, pre-existing conditions (heart attack, stroke, diabetes), subjective health status as compared to before infection, assessed BMI, and performed descriptive statistics.

Results

We investigated 255 participants (50% women, 19-73 years, response rate 20%) ∼20 month (median) after the PCR test. 95% reported symptoms at the time of testing: 67% fatigue, 58% taste disorders, 56% limb pain, 55% odor disorders, 54% headache, 50% cough, 43% fever; 10% needed hospitalization, 3% intensive care, 1.6% artificial ventilation. Compared to the non-hospitalized the formerly inpatients were more often male (62% vs 49%), older (56±13 vs 49±14 years), less often never smokers (42% vs 53%), had a higher BMI (31±7 vs 28±5 kg/m2), and more pre-existing conditions (23% vs 10%). Compared to before infection, 53% rated their current health worse, with a higher rate among inpatients (81%). After ∼1.5 years, 55% still reported symptoms: 25% fatigue, 20% concentration disorder, 18% breathing problems, 13% odor and 11% taste disorders. Persistent symptoms were more common in inpatients than in non-hospitalized (69% vs 53%).

Conclusions

Symptomatic individuals are more likely to participate in a COVID19 follow-up study than asymptomatic ones. This may overestimate the number of individuals with long-term symptoms in population-based long-COVID study populations. However, persistent symptoms seem to be more likely in formerly inpatients compared to non-hospitalized individuals with former SARS-CoV-2 infection.

Key messages

• Symptomatic individuals are more likely to participate in a COVID19 follow-up study than asymptomatic ones.

• Persistent symptoms seem to be more likely in formerly inpatients compared to non-hospitalized individuals with former SARS-CoV-2 infection.

How safe are paediatric emergency departments? A national prospective cohort study

BACKGROUND

Despite the high number of children treated in emergency departments, patient safety risks in this setting are not well quantified. Our objective was to estimate the risk and type of adverse events, as well as their preventability and severity, for children treated in a paediatric emergency department.

METHODS

Our prospective, multicentre cohort study enrolled children presenting for care during one of 168 8-hour study shifts across nine paediatric emergency departments. Our primary outcome was an adverse event within 21 days of enrolment which was related to care provided at the enrolment visit. We identified 'flagged outcomes' (such as hospital visits, worsening symptoms) through structured telephone interviews with patients and families over the 21 days following enrolment. We screened admitted patients' health records with a validated trigger tool. For patients with flags or triggers, three reviewers independently determined whether an adverse event occurred.

RESULTS

We enrolled 6376 children; 6015 (94%) had follow-up data. Enrolled children had a median age of 4.3 years (IQR 1.6-9.8 years). One hundred and seventy-nine children (3.0%, 95% CI 2.6% to 3.5%) had at least one adverse event. There were 187 adverse events in total; 143 (76.5%, 95% CI 68.9% to 82.7%) were deemed preventable. Management (n=98, 52.4%) and diagnostic issues (n=36, 19.3%) were the most common types of adverse events. Seventy-nine (42.2%) events resulted in a return emergency department visit; 24 (12.8%) resulted in hospital admission; and 3 (1.6%) resulted in transfer to a critical care unit.

CONCLUSION

In this large-scale study, 1 in 33 children treated in a paediatric emergency department experienced an adverse event related to the care they received there. The majority of events were preventable; most were related to management and diagnostic issues. Specific patient populations were at higher risk of adverse events. We identify opportunities for improvement in care.

Prediction of lifetime cardiovascular risk and individual lifetime treatment benefit in four European risk regions: geographic recalibration of the LIFE-CVD model

Background

The life expectancy free of cardiovascular disease (CVD) in individuals without previous CVD can be estimated with the LIFEtime-perspective CardioVascular Disease (LIFE-CVD) model, as recommended by the 2021 ESC CVD prevention guidelines. Our aim was to systematically recalibrate the LIFE-CVD model to four European risk regions using contemporary and representative registry data.

Methods and results

The LIFE-CVD model was systematically recalibrated to four distinct risk regions within Europe, using representative aggregate data on age- and sex-specific expected CVD and non-CVD mortality incidences and risk factor distributions. For external validation, 1,451,077 individuals without previous CVD were included from seven European cohorts, with 53,721 CVD events and 62,902 non-CVD deaths during follow up. After applying the recalibrated risk prediction models to external validation cohorts, C-indices (figure 1) ranged from 0.670 (95% CI 0.650–0.690) to 0.787 (95% CI 0.785–0.789). Predicted risks matched the observed risks in the CPRD data. With the recalibrated LIFE-CVD model, the estimated gain in CVD-free life expectancy from preventive therapy differed per region, for example a 50-year-old smoking women with a systolic blood pressure of 140mm Hg was estimated to gain 0.4 years of CVD-free life from 10 mm Hg SBP reduction in the low risk region, whereas this would be 1.5 years in the very high risk region (figure 2).

Interpretation

By taking into account geographical differences in CVD incidence, the recalibrated LIFE-CVD model provides a more accurate tool for the prediction of lifetime risk and CVD-free life expectancy for individuals without previous CVD, facilitating shared decision-making in cardiovascular prevention options as recommended by the 2021 European Prevention Guidelines.

Funding Acknowledgement

Type of funding sources: None.

Prognostic and predictive value of CA 19-9 in locally advanced pancreatic cancer treated with multiagent induction chemotherapy: results from a prospective, multicenter phase II trial (NEOLAP-AIO-PAK-0113)

BACKGROUND

The prognostic and predictive value of carbohydrate antigen 19-9 (CA 19-9) in locally advanced pancreatic cancer (LAPC) has not yet been defined from prospective randomized controlled trials (RCTs).

PATIENTS AND METHODS

A total of 165 LAPC patients were treated within the NEOLAP RCT for 16 weeks with multiagent induction chemotherapy [ICT; either nab-paclitaxel/gemcitabine alone or nab-paclitaxel/gemcitabine followed by FOLFIRINOX (combination of fluorouracil, leucovorin, irinotecan, and oxaliplatin)] followed by surgical exploration of all patients without evidence of disease progression. CA 19-9 was determined at baseline and after ICT and correlated with overall survival (OS) and secondary R0 resection rate.

RESULTS

From the NEOLAP study population (N = 165) 133 patients (81%) were evaluable for CA 19-9 at baseline and 81/88 patients (92%) for post-ICT CA 19-9 response. Median OS (mOS) in the CA 19-9 cohort (n = 133) was 16.2 months [95% confidence interval (CI) 13.0-19.4] and R0 resection (n = 31; 23%) was associated with a significant survival benefit [40.8 months (95% CI 21.7-59.8)], while R1 resected patients (n = 14; 11%) had no survival benefit [14.0 (95% CI 11.7-16.3) months, hazard ratio (HR) 0.27; P = 0.001]. After ICT most patients showed a CA 19-9 response (median change from baseline: -82%; relative decrease ≥55%: 83%; absolute decrease to ≤50 U/ml: 43%). Robust CA 19-9 response (decrease to ≤50U/ml) was significantly associated with mOS [27.8 (95% CI 18.4-37.2) versus 16.5 (95% CI 11.7-21.2) months, HR 0.49; P = 0.013], whereas CA 19-9 baseline levels were not prognostic for OS. Multivariate analysis demonstrated that a robust CA 19-9 response was an independent predictive factor for R0 resection. Using a CA 19-9 decrease to ≤61 U/ml as optimal cut-off (by receiver operating characteristic analysis) yielded 72% sensitivity and 62% specificity for successful R0 resection, whereas CA 19-9 nonresponders (<20% decrease or increase) had no chance for successful R0 resection.

CONCLUSIONS

CA 19-9 response after multiagent ICT provides relevant prognostic and predictive information and is useful in selecting LAPC patients for explorative surgery.

CLINICAL TRIAL NUMBER

ClinicalTrials.govNCT02125136; https://clinicaltrials.gov/ct2/show/NCT02125136; EudraCT 2013-004796-12; https://www.clinicaltrialsregister.eu/ctr-search/trial/2013-004796-12/results.

Evaluation of parent and youth experiences in advisory groups as part of a mental healthcare clinical trial: protocol for a mixed-method study

INTRODUCTION

Patient engagement in healthcare research is a necessity to ensure that research objectives align with priorities, outcomes and needs of the population under study, and to facilitate ease of implementation and adoption of findings. In clinical trials, there is an increasing focus on patient engagement during the planning and conduct of clinical trials due to the potential for ethical and methodological benefits. As patient engagement in clinical trials increases, there is a need to evaluate the approaches of these activities to contribute evidence on what is most appropriate and successful. The purpose of this study is to evaluate patient engagement processes and the activities of patient partners during and after a paediatric mental healthcare trial.

METHODS AND ANALYSIS

Using a mixed-methods study design, we will evaluate patient partners' engagement activities across set time-points during the trial and after trial completion. In this study, the term 'patient partner' is inclusive of two groups of people with lived experience: (1) caregivers (parents, formal/informal caregivers and family), and (2) youth (aged 15-24 years). Engagement will be evaluated using the participant and project questionnaires of the Public and Patient Engagement Evaluation Tool (PPEET), followed sequentially by semi-structured interviews. Quantitative data from the PPEET questionnaire will be analysed and reported using descriptive statistics. Data from open-ended questions from the PPEET questionnaires and semi-structured interviews will be analysed using thematic analysis.

ETHICS AND DISSEMINATION

Approval from Athabasca University Research Ethics Board will be obtained for this project. Findings will be disseminated at both academic and public venues whether in-person or online, and using platforms that are caregiver and youth friendly.

TRIAL REGISTRATION NUMBER

NCT04902391.

Clinical practice guideline recommendations for pediatric injury care: protocol for a systematic review

INTRODUCTION

Evidence suggests the presence of deficiencies in the quality of care provided to up to half of all paediatric trauma patients in Canada, the USA and Australia. Lack of adherence to evidence-based recommendations may be driven by lack of knowledge of clinical practice guidelines (CPGs), heterogeneity in recommendations or concerns about their quality. We aim to systematically review CPG recommendations for paediatric injury care and appraise their quality.

METHODS AND ANALYSIS

We will identify CPG recommendations through a comprehensive search strategy including Medical Literature Analysis and Retrieval System Online, Excerpta Medica dataBASE, Cochrane library, Web of Science, ClinicalTrials and websites of organisations publishing recommendations on paediatric injury care. We will consider CPGs including at least one recommendation targeting paediatric injury populations on any diagnostic or therapeutic intervention from the acute phase of care with any comparator developed in high-income countries in the last 15 years (January 2007 to a maximum of 6 months prior to submission). Pairs of reviewers will independently screen titles, abstracts and full text of eligible articles, extract data and evaluate the quality of CPGs and their recommendations using Appraisal of Guidelines Research and Evaluation (AGREE) II and AGREE Recommendations Excellence instruments, respectively. We will synthesise evidence on recommendations using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) Evidence-to-Decision framework and present results within a recommendations matrix.

ETHICS AND DISSEMINATION

Ethics approval is not a requirement as this study is based on available published data. The results of this systematic review will be published in a peer-reviewed journal, presented at international scientific meetings and distributed to healthcare providers.

PROSPERO REGISTRATION NUMBER

International Prospective Register of Systematic Reviews (CRD42021226934).

Management of Wheezy Preschoolers in the Emergency Department: A Discrete Choice Experiment

OBJECTIVES

This study aimed to elicit pediatric emergency physician's treatment choices for preschool-aged children with wheeze, determine the characteristics of the presenting child that influence treatment choices, and determine whether there is clinical equipoise by eliciting physician willingness to enroll these children in a placebo-controlled trial of corticosteroids.

METHODS

Discrete choice experiments varying the characteristics of the presenting child were designed to elicit Canadian emergency physician's treatment choices, both in the emergency department (ED) and at discharge, for young children presenting with wheeze and their willingness to enroll in a randomized controlled trial (RCT).

RESULTS

Most physicians chose to treat children with albuterol both in the ED and at discharge for all clinical scenarios. The proportion of physicians who chose to treat children with oral corticosteroids both in the ED and at discharge varied widely (from 12% to 81%) across all scenarios. Physician preference whether preschool children with wheeze should be treated with corticosteroids varied depending on the child's age, history of atopy, and previous and continuous wheeze. Between 73% and 86% of physicians were willing to enroll these children in an RCT indicating clinical equipoise.

CONCLUSIONS

Physician treatment choices varied widely indicating clinical equipoise as to the effectiveness of corticosteroids in this population of patients. Management choices with respect to albuterol and corticosteroids were not consistent with published national and international guidelines. In line with this finding, physician's considerable willingness to enroll these children in an RCT may suggest that they are seeking guidance on how to manage these patients.

Adverse events in the paediatric emergency department: a prospective cohort study

BACKGROUND

Understanding adverse events among children treated in the emergency department (ED) offers an opportunity to improve patient safety by providing evidence of where to focus efforts in a resource-restricted environment.

OBJECTIVE

To estimate the risk of adverse events, their type, preventability and severity, for children seen in a paediatric ED.

METHODS

This prospective cohort study examined outcomes of patients presenting to a paediatric ED over a 1-year period. The primary outcome was the proportion of patients with an adverse event (harm to patient related to healthcare received) related to ED care within 3 weeks of their visit. We conducted structured telephone interviews with all patients and families over a 3-week period following their visit to identify flagged outcomes (such as repeat ED visits, worsening symptoms) and screened admitted patients' health records with a validated trigger tool. For patients with flagged outcomes or triggers, three ED physicians independently determined whether an adverse event occurred.

RESULTS

Of 1567 eligible patients, 1367 (87.2%) were enrolled and 1319 (96.5%) reached in follow-up. Median patient age was 4.34 years (IQR 1.5 to 10.57 years) and most (n=1281; 93.7%) were discharged. Among those with follow-up, 33 (2.5%, 95% CI 1.8% to 3.5%) suffered an adverse event related to ED care. None experienced more than one event. Twenty-nine adverse events (87.9%, 95% CI 72.7% to 95.2%) were deemed preventable. The most common types of adverse events (not mutually exclusive) were management issues (51.5%), diagnostic issues (45.5%) and suboptimal follow-up (15.2%).

CONCLUSION

One in 40 children suffered adverse events related to ED care. A high proportion of events were preventable. Management and diagnostic issues warrant further study.

Kids' Outcomes And Long-term Abilities (KOALA): protocol for a prospective, longitudinal cohort study of mild traumatic brain injury in children 6 months to 6 years of age

INTRODUCTION

Mild traumatic brain injury (mTBI) is highly prevalent, especially in children under 6 years. However, little research focuses on the consequences of mTBI early in development. The objective of the Kids' Outcomes And Long-term Abilities (KOALA) study is to document the impact of early mTBI on children's motor, cognitive, social and behavioural functioning, as well as on quality of life, stress, sleep and brain integrity.

METHODS AND ANALYSES

KOALA is a prospective, multicentre, longitudinal cohort study of children aged 6 months to 6 years at the time of injury/recruitment. Children who sustain mTBI (n=150) or an orthopaedic injury (n=75) will be recruited from three paediatric emergency departments (PEDs), and compared with typically developing children (community controls, n=75). A comprehensive battery of prognostic and outcome measures will be collected in the PED, at 10 days, 1, 3 and 12 months postinjury. Biological measures, including measures of brain structure and function (magnetic resonance imaging, MRI), stress (hair cortisol), sleep (actigraphy) and genetics (saliva), will complement direct testing of function using developmental and neuropsychological measures and parent questionnaires. Group comparisons and predictive models will test the a priori hypotheses that, compared with children from the community or with orthopaedic injuries, children with mTBI will (1) display more postconcussive symptoms and exhibit poorer motor, cognitive, social and behavioural functioning; (2) show evidence of altered brain structure and function, poorer sleep and higher levels of stress hormones. A combination of child, injury, socioenvironmental and psychobiological factors are expected to predict behaviour and quality of life at 1, 3 and 12 months postinjury.

ETHICS AND DISSEMINATION

The KOALA study is approved by the Sainte-Justine University Hospital, McGill University Health Centre and University of Calgary Conjoint Health Research Ethics Boards. Parents of participants will provide written consent. Dissemination will occur through peer-reviewed journals and an integrated knowledge translation plan.

109 Near-fatal suicide attempts among Canadian Youth: A CPSP Study

Background

Suicide is the second leading cause of death among Canadian adolescents. Youth who make near fatal suicide attempts, such as those requiring intensive care unit (ICU) level care, are the closest proxy to those that die by suicide; however, there is limited data on this group.

Objectives

To evaluate the minimum incidence rate and patterns of presentation of youth (under 18 years of age) admitted to the ICU for medically serious self-inflicted injury.

Design/Methods

From January 2017 to December 2018, over 2,700 paediatricians/subspecialist members of the Canadian Paediatric Surveillance Program were electronically surveyed on a monthly basis regarding cases of medically serious self-harm. Participants completed a detailed questionnaire about the reported case and descriptive statistics were used for analyses.

Results

Ninety-four cases (71 female; mean age 15.2 years) of confirmed (n=87) and suspected/probable (n=7) medically serious self-harm were reported. The majority (87%) of cases were reported from 4 out of 13 provinces and territories in Canada (Alberta, British Columbia, Ontario, Quebec). There were 11 deaths by suicide (M&gt;F; p&lt;.05). Medication ingestion was the most common method of self-harm among females (76% F vs. 52% M; p=.03) compared with hanging among males (14% F vs. 39% M; p=.009). More females than males had a prior suicide attempt (62% F vs. 32% M; p=.07) and a history of non-suicidal self-injury (NSSI) (65% F vs. 14% M; p&lt;.05), although only history of NSSI reached significance. More females than males had a past psychiatric diagnosis (77% F vs. 55% M; p=.05), and past use of mental health services (69% F vs. 30% M; p&lt;.001), although only service use reached significance. Half of the youth left evidence of intent (54%) and 33% of parents of included youth were aware that their child was considering suicide. Family conflict was the most common precipitating factor for suicide attempt in both females and males (46%).

Conclusion

These Canadian findings are consistent with international epidemiologic data that observe a gender paradox of higher rates of suicide attempts in females and greater mental health care engagement but increased suicide mortality in males with decreased involvement with mental health care. This study suggests that family conflict is a potential target for suicide prevention interventions among youth. Future research focusing on gender-specificity in risk factor identification and effectiveness of primary prevention interventions among youth is warranted.

Study protocol for two complementary trials of non-steroidal or opioid analgesia use for children aged 6 to 17 years with musculoskeletal injuries (the No OUCH study)

INTRODUCTION

Musculoskeletal (MSK) injuries are a frequent cause for emergency department (ED) visits in children. MSK injuries are associated with moderate-to-severe pain in most children, yet recent research confirms that the management of children's pain in the ED remains inadequate. Clinicians are seeking better oral analgesic options for MSK injury pain with demonstrated efficacy and an excellent safety profile. This study aims to determine the efficacy and safety of adding oral acetaminophen or oral hydromorphone to oral ibuprofen and interpret this information within the context of parent/caregiver preference.

METHODS AND ANALYSIS

Using a novel preference-informed complementary trial design, two simultaneous trials are being conducted. Parents/caregivers of children presenting to the ED with acute limb injury will be approached and they will decide which trial they wish to participate in: an opioid-inclusive trial or a non-opioid trial. Both trials will follow randomised, double-blind, placebo-controlled, superiority-trial methodology and will enrol a minimum of 536 children across six Canadian paediatric EDs. Children will be eligible if they are 6 to 17 years of age and if they present to the ED with an acute limb injury and a self-reported verbal Numerical Rating Scale pain score ≥5. The primary objective is to determine the effectiveness of oral ibuprofen+oral hydromorphone versus oral ibuprofen+oral acetaminophen versus oral ibuprofen alone. Recruitment was launched in April 2019.

ETHICS AND DISSEMINATION

This study has been approved by the Health Research Ethics Board (University of Alberta), and by appropriate ethics boards at all recruiting centres. Informed consent will be obtained from parents/guardians of all participants, in conjunction with assent from the participants themselves. Study data will be submitted for publication regardless of results. This study is funded through a Canadian Institutes of Health Research grant.

TRIAL REGISTRATION NUMBER

NCT03767933, first registered on 07 December 2018.

Incidence and mortality for cutaneous squamous cell carcinoma: comparison across three continents

BACKGROUND

Population-based incidence and mortality studies of cutaneous squamous cell carcinoma (SCC) have been few owing to the commonness of the disease, and rare deaths making accurate mortality statistics difficult.

OBJECTIVES

Our aim was to summarize SCC incidence and mortality in populations across three continents, exemplified by Australia, the United States (US) and Germany.

METHODS

We estimated age-specific and age-standardized (Australian Standard 2001 Population) incidence and mortality rates per 100 000 person-years.

RESULTS

Squamous cell carcinoma incidence is plateauing or falling in Australia, stable in the United States (2013-2015) and rising in Germany (2007-2015). Current incidence estimates in men and women are 341 and 209, 497 and 296, and 54 and 26, respectively, for the three countries. Incidence increases strongly with age in all countries. Mortality of non-melanoma skin cancer appears to be increasing in Germany and stable in Australia (unavailable for the US population).

CONCLUSIONS

Squamous cell carcinoma is an important health issue, particularly among older men, with incidence exceeding most other cancers. More precise and uniform population-based studies of incidence and mortality are needed to better quantify the impact of SCC on healthcare systems worldwide and to gauge the effect of new treatments such as anti-PD1 therapy on mortality.

The impact of pediatric emergency department crowding on patient and health care system outcomes: a multicentre cohort study

BACKGROUND

Emergency department overcrowding has been associated with increased odds of hospital admission and mortality after discharge from the emergency department in predominantly adult cohorts. The objective of this study was to evaluate the association between crowding and the odds of several adverse outcomes among children seen at a pediatric emergency department.

METHODS

We conducted a retrospective cohort study involving all children visiting 8 Canadian pediatric emergency departments across 4 provinces between 2010 and 2014. We analyzed the association between mean departmental length of stay for each index visit and hospital admission within 7 days or death within 14 days of emergency department discharge, as well as hospital admission at index visit and return visits within 7 days, using mixed-effects logistic regression modelling.

RESULTS

A total of 1 931 465 index visits occurred across study sites over the 5-year period, with little variation in index visit hospital admission or median length of stay. Hospital admission within 7 days of discharge and 14-day mortality were low across provinces (0.8%-1.5% and < 10 per 100 000 visits, respectively), and their association with mean departmental length of stay varied by triage categories and across sites but was not significant. There were increased odds of hospital admission at the index visit with increasing departmental crowding among visits triaged to Canadian Triage and Acuity Scale (CTAS) score 1-2 (odds ratios [ORs] ranged from 1.01 to 1.08) and return visits among patients with a CTAS score of 4-5 discharged at the index visit at some sites (ORs ranged from 1.00 to 1.06).

INTERPRETATION

Emergency department crowding was not significantly associated with hospital admission within 7 days of the emergency department visit or mortality in children. However, it was associated with increased hospital admission at the index visit for the sickest children, and with return visits to the emergency department for those less sick.

The impact of pediatric emergency department crowding on patient and health care system outcomes: a multicentre cohort study

BACKGROUND

Emergency department overcrowding has been associated with increased odds of hospital admission and mortality after discharge from the emergency department in predominantly adult cohorts. The objective of this study was to evaluate the association between crowding and the odds of several adverse outcomes among children seen at a pediatric emergency department.

METHODS

We conducted a retrospective cohort study involving all children visiting 8 Canadian pediatric emergency departments across 4 provinces between 2010 and 2014. We analyzed the association between mean departmental length of stay for each index visit and hospital admission within 7 days or death within 14 days of emergency department discharge, as well as hospital admission at index visit and return visits within 7 days, using mixed-effects logistic regression modelling.

RESULTS

A total of 1 931 465 index visits occurred across study sites over the 5-year period, with little variation in index visit hospital admission or median length of stay. Hospital admission within 7 days of discharge and 14-day mortality were low across provinces (0.8%-1.5% and < 10 per 100 000 visits, respectively), and their association with mean departmental length of stay varied by triage categories and across sites but was not significant. There were increased odds of hospital admission at the index visit with increasing departmental crowding among visits triaged to Canadian Triage and Acuity Scale (CTAS) score 1-2 (odds ratios [ORs] ranged from 1.01 to 1.08) and return visits among patients with a CTAS score of 4-5 discharged at the index visit at some sites (ORs ranged from 1.00 to 1.06).

INTERPRETATION

Emergency department crowding was not significantly associated with hospital admission within 7 days of the emergency department visit or mortality in children. However, it was associated with increased hospital admission at the index visit for the sickest children, and with return visits to the emergency department for those less sick.

Associations of metabolically healthy obesity with prevalence and progression of coronary artery calcification: Results from the Heinz Nixdorf Recall Cohort Study

BACKGROUND AND AIMS

There is controversy on the potentially benign nature of metabolically healthy obesity (MHO), i.e., obese persons with few or no metabolic abnormalities. So far, associations between MHO and coronary artery calcification (CAC), a measure of subclinical atherosclerosis, have mainly been studied cross-sectionally in Asian populations. We assessed cross-sectional and longitudinal MHO CAC associations in a Caucasian population.

METHODS AND RESULTS

In the Heinz Nixdorf Recall Study, a population-based cohort study in Germany, CAC was assessed by electron-beam tomography at baseline and at 5-year follow-up. For cross-sectional and longitudinal analyses, we included 1585 participants free of coronary heart disease at baseline, with CAC measurements at baseline and at follow-up, and with either normal weight (BMI 18.5-24.9 kg/m²) or obesity (BMI ≥30.0 kg/m²) at baseline. We used four definitions of MHO. In our main analysis, we defined obese persons as metabolically healthy if they met ≤1 of the NCEP ATP III criteria for the definition of the metabolic syndrome - waist circumference was not taken into account because of collinearity with BMI. Persons with MHO had a higher prevalence of CAC than metabolically healthy normal weight (MHNW) persons (prevalence ratio = 1.59 (95% confidence interval 1.38-1.84) for the main analysis). Persons with MHO had slightly larger odds of CAC progression than persons with MHNW (odds ratios ranged from 1.17 (0.69-1.99) to 1.48 (1.02-2.13) depending on MHO definition and statistical approach).

CONCLUSION

Our analyses on MHO CAC associations add to the evidence that MHO is not a purely benign health condition.

Incidence of testicular tumor subtypes according to the updated WHO classification, North Rhine-Westphalia, Germany, 2008-2013

BACKGROUND

In 2016, the WHO introduced an updated classification for testicular tumors. The application of this updated classification to cancer registry data requires some recoding of tumors.

OBJECTIVES

The aim of this study was to provide up-to-date population-based incidence estimates of subtypes of testicular germ cell tumors (TGCT) according to the updated classification.

MATERIAL AND METHODS

We reviewed 2251 pathology reports (42.9%) out of 5252 testicular tumors at the cancer registry of North Rhine-Westphalia for the years 2008-2013. We used population counts to estimate age-standardized incidence rates per million person-years (EUROSTAT revised European Standard Population).

RESULTS

The application of the updated WHO classification resulted in a recoding of 8.9% of all testicular tumors. While the recodings have no influence on the incidence of seminomatous and non-seminomatous TGCTs that include mixed TGCTs, they influence the incidence of individual histological types of seminomatous and non-seminomatous TGCTs. Among the 4935 testicular germ cell tumors (TGCT), 23.7% were mixed TGCTs. Overall, 46.9% of all mixed TGCTs included seminoma and age-standardized incidence rates were highest for the combination seminoma plus embryonal carcinoma (5.9 per million person-years) and embryonal carcinoma plus teratoma (4.9 per million person-years). The median age at diagnosis was higher for mixed TGCTs including seminoma (31 years) than those that did not include seminoma (28 years).

DISCUSSION AND CONCLUSIONS

Population-based incidence time trends for seminomatous and non-seminomatous TGCTs that include mixed TGCTs are not distorted by the introduction of the WHO update. Trend distortions can only be expected if time trends of individual histological subtypes of the seminomatous and non-seminomatous TGCTs are examined.

Treating and reducing anxiety and pain in the paediatric emergency department-TIME FOR ACTION-the TRAPPED quality improvement collaborative

BACKGROUND/OBJECTIVES

In 2013, the TRAPPED-1 survey reported inconsistent availability of pain and distress management strategies across all 15 Canadian paediatric emergency department (PEDs). The objective of the TRAPPED-2 study was to utilize a procedural pain quality improvement collaborative (QIC) and evaluate the number of newly introduced pain and distress-reducing strategies in Canadian PEDs over a 2-year period.

METHODS

A QIC was created to increase implementation of new strategies, through collaborative information sharing among PEDs. In 2015, 11 of the 15 Canadian PEDs participated in the TRAPPED QIC. At the end of the year, the TRAPPED-2 survey was electronically sent to a representative member at each of the 15 PEDs. The successful introduction of the chosen strategies by the QIC was assessed as well as the addition of new strategies per site. The number of new strategies introduced in the participating and nonparticipating QIC sites were described.

RESULTS

All 15 PEDs (100%) completed the TRAPPED-2 survey. Overall, 10/11 of QIC-participating sites implemented the strategy they had initially identified. All 15 Canadian PEDs implemented some new strategies during the study period; participants in the QIC reported a mean of 5.2 (1-11) new strategies compared to 2.5 (1-4) in the nonactively participating sites.

CONCLUSION

While all PEDs introduced new strategies during the study, QIC-participating sites successfully introduced the majority of their previously identified new strategies in a short time period. Sharing deadlines and information between centres may have contributed to this success.

Bonner Venenstudie der Deutschen Gesellschaft für Phlebologie

Ziel: Die Bonner Venenstudie zur Frage der Häufigkeit und Ausprägung von chronischen Venenkrankheiten in der städtischen und ländlichen deutschen Wohnbevölkerung im Alter von 18-79 Jahren fand zwischen dem 13. 11. 2000 und 15. 3. 2002 statt. Es nahmen insgesamt 3072 Probanden teil, die Response-Proportion lag insgesamt bei 59%. Ergebnisse: Eine Beinschwellung in der Anamnese trat bei jedem 6. Mann (16,2%) und bei nahezu jeder 2. Frau (42,1%) auf. Eine kurz zurückliegende ein- oder beidseitige Beinschwellung in den letzten vier Wochen gab jeder 6. Teilnehmer an. Dies entspricht 14,8% (7,9% der Männer, 20,2% der Frauen). Für Gefäßerkrankungen typische Beinbeschwerden innerhalb der letzten vier Wochen gab insgesamt jeder 2. der Probanden (56,4%) an. Bei der Beurteilung der klinischen Ausprägung gemäß der CEAP-Klassifikation fällt auf, dass lediglich 9,6% der Probanden keinerlei Venenveränderungen aufweisen. Bei 59% bestehen isoliert Teleangiektasien oder retikuläre Venen, bei 14,3% Krampfadern (C2) ohne weitere Zeichen einer chronischen venösen Insuffizienz. Auffällig ist, dass bei 13,4% ein prätibiales Ödem im Rahmen von Venenveränderungen zum Untersuchungszeitpunkt vorlag. Demgegenüber liegt die Zahl der fortgeschrittenen Zeichen der chronischen venösen Insuffizienz bei 3,3%. Die Häufigkeit des floriden oder abgeheilten Ulcus cruris lag bei 0,7%. Schlussfolgerungen: Jeder 6. Mann und jede 5. Frau hat somit chronische Veneninsuffizienz (C3–C6). Die Zahlen zeigen, dass Venenkrankheiten insgesamt nach wie vor eine hohe Prävalenz aufweisen, dass aber die schweren Ausprägungen der chronischen venösen Insuffizienz in den vergangenen 20 Jahren zurückgegangen sind.

Prevalence of Stemmer's sign in the general population

Lymphoedema is a disease frequently diagnosed in vascular departments, its origin being primary or secondary after cellulitis or cancer treatment. The prevalence of lower extremity lymphoedema in the general population is largely unknown. The aim of this article is to describe the prevalence of Stemmer's sign as a diagnostic criterium for lymphoedema in an unselected adult German population. Methods: The population for this cross-sectional study was recruited from November 2000 through March 2002 from the general population of the city of Bonn and two surrounding rural communities. 3072 individuals (1145 rural and 1927 urban) could be enrolled in the study. The results of the clinical examination were categorized in four groups: grade 0 normal skin fold at the dorsum of the second toe, grade 1 skin fold enlarged measuring 0.5–1 cm, grade 2 the skin fold >1 cm and grade 3 >1 cm with severe induration or papillomatosis. Results: Among 3055 out of 3072 subjects information on all variables were available. In 15.9% of the population a positive Stemmer sign was found with a slightly higher overall prevalence in women. Most of this group presented as grade 1 Stemmer's sign (14.1%). The more severe grades 2 and 3 were present in 1.8 % of the study population with no clear difference between sexes. We observed a considerably higher prevalence of Stemmer's sign of all grades in the urban population. The prevalence of Stemmer's sign increased with age from 3.2% up to 35.9% in the 70–79 year old population. Prevalence of positive Stemmer's sign was also higher in higher C-stages of the CEAP classification (5.8% in C0 to 100% in C6). Conclusions: The prevalence of lymphoedema in the general population represented by grade 2–3 Stemmer's sign in 1.8% and grade 1 Stemmer's sign in 14% is high. Women have a slightly higher prevalence of positive Stemmer's sign than men. The prevalence of positive Stemmer's sign is associated with age and chronic venous insufficiency.

Prevalence and acceptance of therapy with medical compression stockings

The aim of this study was to assess the prevalence of use of medical compression stockings (MCS) in the general adult population in Germany, to comment the indications for which MCS therapy has been described and the patients’ experience with it. Methods: The survey is based on the Bonn Vein Study. The population of this cross-sectional study was randomly recruited between November 2000 and March 2002 from the registers of residents of the city of Bonn and two rural townships in the area. In total, 3.072 men and women were included in the trial. In addition to clinical examination and duplex-ultrasound, participants were asked whether any phlebological treatment had been carried out due to a leg disorder or disease.. If compression stockings had been worn, we asked for details such as compression class and length of stockings, wearing time, effectiveness, and recognition. Results: In total, 22.9% of people providing information (12.7% of male, 31.0% of female) mentioned having received a specific phlebological treatment in the past. Therapy with compression stockings had the highest prevalence with 14.6% in the general population (7.5% of males, 20.3% of females). The mean age at the first prescription was 45.5 years (SD = 14.3 years). With increasing severity of venous disease, as rated according to the CEAP classification, the prevalence increased from 1% in C0 patients to 82% in C5/C6 patients. Of 450 participants who had used compression stockings in the past, 309 (68.6%) did not wear CS at the time of the survey. The remainder had generally been wearing them on five or more days per week (73.0%) for 8 or more hours per day (89.4%). On average, 71.3% of the participants said that the disease for which MCS were prescribed, had improved as a result of MCS therapy. Improvement concerned a reduction of sensations of swelling (84.2%), of heaviness (89.4%), leg pain after long periods of standing (60.9), and tension in the legs (78.9).

Safe Care for Pediatric Patients: A Scoping Review Across Multiple Health Care Settings

Children are particularly vulnerable to patient safety concerns due to pediatric-specific and general health care challenges. This scoping review identifies and describes the vulnerabilities of those aged 0 to 18 years to iatrogenic harm in various health care settings. Six databases were searched from 1991 to 2012. Primary studies were categorized using predetermined groupings. Categories were tallied and descriptive statistics were employed. A total of 388 primary studies exploring interventions that improved patient safety, deficiencies, or errors leading to safety concerns were included. The most common issues were medication (189 studies, 48.7%) and general medical (81 studies, 20.9%) errors. Sixty studies (15.5%) evaluated or described patient safety interventions, 206 studies (53.1%) addressed health care systems and technologies, 17 studies (4.4%) addressed caregiver perspectives and 20 studies (5.2%) discussed analytic models for patient safety. Further work is needed to ensure consistency of definitions in patient safety research to facilitate comparison and collation of results.

A systematic review of adverse drug events associated with administration of common asthma medications in children

Objective

To systematically review the literature and determine frequencies of adverse drug events (ADE) associated with pediatric asthma medications.

Methods

Following PRISMA guidelines, we systematically searched six bibliographic databases between January 1991 and January 2017. Study eligibility, data extraction and quality assessment were independently completed and verified by two reviewers. We included randomized control trials (RCT), case-control, cohort, or quasi-experimental studies where the primary objective was identifying ADE in children 1 month– 18 years old exposed to commercial asthma medications. The primary outcome was ADE frequency.

Findings

Our search identified 14,540 citations. 46 studies were included: 24 RCT, 15 cohort, 4 RCT pooled analyses, 1 case-control, 1 open-label trial and 1 quasi-experimental study. Studies examined the following drug classes: inhaled corticosteroids (ICS) (n = 24), short-acting beta-agonists (n = 10), long-acting beta-agonists (LABA) (n = 3), ICS + LABA (n = 3), Leukotriene Receptor Antagonists (n = 3) and others (n = 3). 29 studies occurred in North America, and 29 were industry funded. We report a detailed index of 406 ADE descriptions and frequencies organized by drug class. The majority of data focuses on ICS, with 174 ADE affecting 13 organ systems including adrenal and growth suppression. We observed serious ADE, although they were rare, with frequency ranging between 0.9–6% per drug. There were no confirmed deaths, except for 13 potential deaths in a LABA study including combined adult and pediatric participants. We identified substantial methodological concerns, particularly with identifying ADE and determining severity. No studies utilized available standardized causality, severity or preventability assessments.

Conclusion

The majority of studies focus on ICS, with adrenal and growth suppression described. Serious ADE are relatively uncommon, with no confirmed pediatric deaths. We identify substantial methodological concerns, highlighting need for standardization with future research examining pediatric asthma medication safety.

[Public Health: Setting Goals, Establishing Structures and Improving Health for All]

Public health is a population- and system-based approach that is needed to improve the health of societies and to decrease health inequalities. In the face of global challenges, the public health approach is essential. In Germany, the importance of public health is only partly reflected by its institutions and institutional arrangements. This applies equally to research, teaching and training, as well as to the public health service. Furthermore, the public health perspective is not sufficiently considered in cross-sectional topics that are relevant for health.There have been several initiatives to overcome structural deficits which can partly be traced back to historical circumstances. The White Paper presented here should encourage discussions about future policy options in public health. The authors represent public health in practice, research, and teaching in Germany.

Treating and Reducing Anxiety and Pain in the Paediatric Emergency Department (The Trapped 2 Survey): Time for Action – A Pediatric Emergency Research Canada (Perc) Project

BACKGROUND: Multiples barriers to appropriate analgesia provision are reported in the paediatric emergency department (PED), including limited accessibility to effective strategies.

OBJECTIVES: To evaluate the improvement in the accessibility of pain and anxiety management strategies in PEDs in Canada, after the creation of a national pediatric pain quality improvement collaborative, through Pediatric Emergency Research Canada.

DESIGN/METHODS: In 2013, the TRAPPED 1 survey was administered across Canadian PEDs, in order to evaluate the resources in place for pain and anxiety management. Subsequent to the TRAPPED 1, a pain Quality Improvement Collaborative was created to stimulate the implementation of new pain and anxiety management strategies through the sharing of information between PEDs. The TRAPPED 2 survey involved a cross sectional survey similar to TRAPPED 1, after a two year interval. Its main focus was to evaluate the improvement in the accessibility of specific, preferred strategies reported by each centre, after participating in this collaborative between December 2014 to November 2015, and then working to implement change within their own PEDs.

RESULTS: All 15/15 Canadian PEDs responded to TRAPPED 1 in 2013. In 2014, 11/15 agreed to participate in the national pain Quality Improvement Collaborative, with a goal of introducing new pain and anxiety management strategies within their own PEDs. An in-person meeting, email communication, and telephone meetings were employed for information sharing regarding experiences/challenges within each of the participating centres. Newly introduced strategies included education, distraction, nurse-initiated protocols, and policies/education to encourage the use of intranasal (IN) medications. 11/11 centres have responded to the interim follow up surveys in 2015. At the end of the project (Fall 2105), 15/15 Canadian PEDs agreed to complete the final TRAPPED 2 survey. When comparing the results of 2015 with 2013, an increased number of PEDs used face-based pain scales (14/15 vs 6/15) and behavioural scales (5/15 vs 1/15) for pain assessment of school-aged children and infants, respectively. Use of assessment room wall decoration for distraction increased from 7/15 to 11/15. Reminder posters for pain management at triage increased from 4/15 to 6/15. Availability of electronic distraction strategies (e.g. using tablets) increased from 4/15 to 10/15 centres. For skin-piercing procedure, nurses initiated protocols to use topical anesthetic creams and oral sucrose was available in 12/15 centres (compared to 10/15 in 2013), and 14/15 (compared to 12/15 in 2013) respectively. Availability of IN medications increased in the last two years: fentanyl 14/15 (9/15 in 2013) and midazolam in at least 10/15 (8/15 in 2013). 10/11 PEDS involved in the QI strategy reported the implementation of at least one of their strategies identified.

CONCLUSION: This study suggests that the use of a pain Quality Improvement Collaborative may improve the introduction of new strategies in multiple PEDs. It can help guide other centres when introducing new strategies to reduce pain and anxiety for children in community EDs. Future research can focus on the sustainability of the strategies, and as well the effect of the collaborative on the introduction of other pain treatment strategies.

Family Perceptions and Provision of Analgesia for Acutely Painful Conditions in Children: A Multi-Centred Prospective Survey

BACKGROUND: More than two-thirds of children who present to the emergency department (ED) complain of pain. It is well known that children’s pain is poorly managed in the ED compared to their adult counterparts. With respect to analgesic administration in the ED, discrepancies exist between physician self-report and institutional audit. Patient refusal of analgesia is a likely explanation. There is good evidence that misconceptions and fears about analgesia in children are common among caregivers and may contribute to withholding pain medication. To date, no study has surveyed caregivers presenting the the ED to assess frequency of analgesic administration and reasons for withholding analgesia. We hypothesize that there will be a significant proportion of care-givers and patients that refuse pain medication in the ED. We also hypothesize that there will be a wide range of reasons for refusal. The insight we gain from this study will help nurses, clinical educators, and physicians provide the appropriate information to parents in an effort to target misconceptions and allay fears.

OBJECTIVES: Our objectives were to characterize the degree of care-giver and patient provision of analgesia prior to arrival, refusal of analgesia in the ED, and reasons behind their decision-making process. We hope to identify specific misconceptions, attitudes, or beliefs that impair the optimal provision of analgesia to children in the ED.

DESIGN/METHODS: A novel survey was designed by a focus group using an iterative approach and implemented over a 16-week period across two Canadian tertiary care paediatric EDs. We included a consecutive sample of caregivers of children aged 4-17 years with an acutely painful condition (headache, abdominal pain, injury, otitis, pharyngitis). Caregivers were asked to answer questions covering five domains: (i) demographics, (ii) analgesia prior to arrival (iii) analgesia offered in the ED and reasons for refusal, (iv) perceptions of analgesia, and (v) caregiver satisfaction at discharge. Children were asked to rate their pain on arrival and at discharge. The primary outcome was the frequency of caregiver provision of analgesia prior to arrival and the proportion of caregivers who accept the offer of analgesia offered in the ED.

RESULTS: Three hundred forty-four caregivers completed the survey. The majority were female (269/339, 79%), aged 36 years or older (256/340, 75%) with a post-secondary education (237/336, 71%). Most (309/339, 91%) reported being able to “tell when their child was in pain”. All respondents rated their child’s maximal pain related to the presenting condition as at least a 6/10. With regards to the primary outcome, 229/338 (68%) of caregivers reported that they did not treat their child’s pain prior to arrival in the ED. Of those who did treat their child’s pain, ibuprofen was the most commonly used analgesic (77/112, 69%). The most common reasons for withholding analgesia was a lack of time (80/210, 38%), fear of masking seriousness of child’s condition (49/210, 23%), fear of masking signs and symptoms (48/210, 23%), and a lack of analgesia at home (47/210, 22%). Analgesia was offered to 186/344 (45%) of children in the ED and the majority of caregivers 157/186 (84%) accepted the offer. The most common reason for not accepting analgesia in the ED was child refusal (15/20, 75%). Most, 231/338 (68%) of caregivers felt that their child’s pain was managed well in the ED.

CONCLUSION: This survey of caregiver perceptions surrounding analgesia for children with acutely painful conditions presenting to the pae-diatric ED suggests that most do not treat their child’s pain prior to arrival, despite high levels of pain. Misconceptions surrounding analgesia prior to arrival are common. Despite this, most caregivers accepted analgesia in the ED. Our results suggest that educational strategies should be directed at caregiver awareness of the impact of pain on children and the need for prompt analgesic therapy, even when an ED visit is planned.

[Some Caveats in the Interpretation of Population Attributable Risks]

Population attributable risks (PARs) are often used in health sciences because they offer an apparently easy answer to the question as to the proportion of disease cases that could be prevented in a population if one or more risk factors were eliminated. We discuss some problems in the interpretation of PARs that result from the fact that diseases have more than one cause. Moreover, requirements are discussed which have to be met before PARs can give a realistic idea of the proportion of cases of illness that can be avoided.

A survey of etiologic hypotheses among testicular cancer researchers

Basic research results can provide new ideas and hypotheses to be examined in epidemiological studies. We conducted a survey among testicular cancer researchers on hypotheses concerning the etiology of this malignancy. All researchers on the mailing list of Copenhagen Testis Cancer Workshops and corresponding authors of PubMed-indexed articles identified by the search term 'testicular cancer' and published within 10 years (in total 2750 recipients) were invited to respond to an e-mail-based survey. Participants of the 8th Copenhagen Testis Cancer Workshop in May 2014 were subsequently asked to rate the plausibility of the suggested etiologic hypotheses on a scale of 1 (very implausible) to 10 (very plausible). This report describes the methodology of the survey, the score distributions by individual hypotheses, hypothesis group, and the participants' major research fields, and discuss the hypotheses that scored as most plausible. We also present plans for improving the survey that may be repeated at a next international meeting of experts in testicular cancer. Overall 52 of 99 (53%) registered participants of the 8th Copenhagen Testis Cancer Workshop submitted the plausibility rating form. Fourteen of 27 hypotheses were related to exposures during pregnancy. Hypotheses with the highest mean plausibility ratings were either related to pre-natal exposures or exposures that might have an effect during pregnancy and in post-natal life. The results of the survey may be helpful for triggering more specific etiologic hypotheses that include factors related to endocrine disruption, DNA damage, inflammation, and nutrition during pregnancy. The survey results may stimulate a multidisciplinary discussion about new etiologic hypotheses of testicular cancer.