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Objectives Resuscitation care planning for extremely low gestational age neonates (ELGANs) is complex and ethically charged. Increasing survival at lower gestational ages has had a significant impact on this complexity. It also has an impact on healthcare resource utilization and policy development in Canada. This study sought to determine the current attitudes and practices of neonatologists in Canada, and to assess moral distress associated with resuscitation decisions in the ELGAN population. It also aimed to explore the perspectives of adopting a shared decision-making approach where further data with regard to best interests and prognosis are gathered in an individualized manner after birth. Methods Neonatologists in Canadian level III NICUs were surveyed in 2020. Results Amongst the 65 responses, 78% expressed moral distress when parents request non-resuscitation at 24 weeks. Uncertainty around long-term outcomes in an era with improved chances of morbidity-free survival was the most prominent factor contributing to moral distress. 70% felt less moral distress deciding goals of care after the baby’s initial resuscitation and preferred an individualized approach to palliation decisions based on postnatal course and assessment. Conclusions While most current guidelines still support the option of non-resuscitation for infants born at less than 25 weeks, we show evidence of moral distress among Canadian neonatologists that suggests the consideration of routine resuscitation from 24 weeks and above is a more ethical approach in the current era of improved outcomes. Canadian neonatologists identified less moral distress when goals of care are developed postnatally, with availability of more evidence for prognostication, instead of antenatally based primarily on gestational age.

Objectives Aromatase deficiency is a rare autosomal recessive disease that results in the absence of aromatase. In females it presents with ambiguous genitalia and lack of secondary sexual characteristics during puberty. Aromatase deficiency is not attributed to any specific population, but it is more commonly seen in consanguineous parents. Herein, we report the first Old Order Mennonite family with that diagnosis. Case presentation Our proband is an Old Order Mennonite female born with ambiguous genitalia who was identified to carry novel homozygous variant in the CYP19A1 gene c.1304G>A (p. Arg435His). Her older brother was later confirmed with the same genetic diagnosis. Conclusions Recognizing the cultural sensitivity, unrecognized affected cases, and late presentation of males affected with aromatase deficiency, this condition may be more prevalent than believed in that population.

Introduction Obstructive Sleep Apnea (OSA) and Nonalcoholic Fatty Liver Disease (NAFLD) are two conditions that have increased in prevalence in the United States. NAFLD is a spectrum of liver disease ranging from steatosis to non-alcoholic steatohepatitis (NASH) to cirrhosis. The purpose of this project is to study the relationship between OSA, measured by apnea-hypopnea index and/or arterial oxygen saturation nadir (O2 nadir) during sleep (independent variable) vs. extent of NAFLD as measured by non-invasive scores such as NAFLD Fibrosis score, aminotransferase to platelet ratio index (APRI), BARD score and FIB-4 score (dependent variable). Methods A convenient sample of 91 haphazardly selected veterans with OSA and NAFLD from the Veterans Affairs (VA) Computerized Record System (CPRS) system were included in the study. NAFLD eligibility was determined by abdominal ultrasound, CT scan, MRI, or biopsy. Dependent variables were NAFLD scores of APRI, NAFLD Fibrosis, BARD, and FIB-4. OSA was determined by in-lab polysomnogram or home sleep study. Independent variables were AHI, O2 nadir, age and body mass index (BMI). Patients with a history of alcohol abuse or Hepatitis B or C were excluded from the study. A multiple regression analysis was used to describe the relationship between OSA and NAFLD scores. P< 0.05 was considered statistically significant. Results Age correlated with FIB-4 score, BARD score, and NAFLD fibrosis score (p = < 0.001, 0.003, < 0.001, respectively). BMI correlated with NAFLD fibrosis score (p < 0.001). When controlled for age and BMI, AHI and O2 nadir did not correlate with APRI, NAFLD fibrosis, BARD, or FIB-4 scores. Conclusion OSA measured by AHI and O2 nadir do not correlate with severity of fatty liver disease as measured by APRI, NAFLD fibrosis, BARD, or FIB-4 scores. Support (if any) None

Introduction Pediatric central sleep apnea (CSA) rarely initially presents in adolescent age groups, being more commonly diagnosed in infants. CSA may result from a multitude of neurological insults, such as stroke and brain masses. It may also less often present in metabolic and non-ischemic thrombotic disorders. Report of case(s) A 12-year-old female with history of global developmental delay of unclear etiology, chronic headaches, insulin resistance, and early morning tremors was referred for initial evaluation of possible narcolepsy. Severe daytime sleepiness had acutely worsened over the previous month. She was unable to stay awake during school, despite sleeping 13 hours per 24 hours. Central hypersomnia was suspected and polysomnogram with MSLT was scheduled. The patient presented to the Emergency Department 10 days later for worsening headaches and new oral aversion with 12-pound weight loss. Examination showed ataxic gait and dysarthria. Brain MRI revealed non-occlusive cerebral sinus venous thrombosis (CSVT) involving the superior sagittal sinus, right transverse sinus, right sigmoid sinus, right jugular bulb/vein, and cortical veins overlying both cerebral hemispheres with no stroke. Anticoagulation with enoxaparin was initiated and thrombophilia work-up commenced. Polysomnogram demonstrated a central AHI of 49.9/hr with significant periodic breathing and no obstructive sleep apnea. Oxygen titration sleep study failed to significantly improve CSA and BPAP was initiated. Thrombophilia work-up revealed severe hyperhomocysteinemia. Genetic analysis was consistent with autosomal recessive severe methylenetetrahydrofolate reductase (MTHFR) deficiency. The patient was begun on metabolic treatment with betaine, pyridoxine, hydroxocobalamin, and vitamin C, and transitioned to oral rivaroxaban. At 4 months, blood levels had normalized, and MRI demonstrated resolution of CSVT. Family endorsed BPAP compliance and complete resolution of all sleep symptoms. In addition, there was significant improvement in cognition, interpersonal skills, and abstract thought. Follow up polysomnogram 10 months after presentation demonstrated no CSA nor periodic breathing. Conclusion To our knowledge, this is the first report of MTHFR deficiency and CSVT resulting in severe CSA. While it is difficult to ascertain which entity ultimately caused the CSA, MTHFR deficiency can produce significant neurologic impairment through white matter disease and defective myelination, while CSVT can provoke venous hypertension, venous stasis, or hypoxia. Support (if any)

Introduction Early diagnosis of pediatric syndromes that are rare and involve multiple systems can be challenging. Rapid onset obesity, hypoventilation, hypothalamic dysfunction, and autonomic dysregulation characterizes ROHHAD syndrome which, if undiagnosed, can lead to potentially harmful outcomes including deferring radiological workup for a neural crest tumor (which has an over 50% association) and cardiopulmonary arrest. Report of case(s) A 10-year-old female with a history of obesity, precocious puberty, recurrent hypothermia, recurrent sodium derangements, bilateral ptosis, seizure disorder, and GERD initially presented to sleep clinic as a 4-year-old in 2017 when she recently began snoring with excessive daytime sleepiness as a result of rapid onset of weight gain. BMI at that time was 99th percentile and Epworth was 11. An in-lab polysomnography revealed severe OSA with AHI 26.4 events/hour; nocturnal hypoxemia with TS90 27% and O2 nadir 70%; and sleep related hypoventilation based on elevated pCO2 on end-tidal capnometry. Patient underwent adenotonsillectomy, revision adenoidectomy, and was started on CPAP before transitioning to BiPAP over the span of the next several years with serial polysomnographies ultimately showing significant improvement of sleep apnea with AHI 5.4 events/hour. Sleep-related hypoventilation, however, remained persistent with blood gases showing pCO2 as high as 89. PHOX2B gene testing was negative and secondary causes of hypoventilation were ruled out. During this time, she was also followed by Endocrinology for suspected hypothalamic dysfunction resulting in precocious puberty, deceleration of growth rate, sodium derangements. Autonomic dysfunction was also suspected due to recurrent hypothermia including a recent admission for Temperature < 95F and ophthalmologic abnormalities including bilateral ptosis. At a multidisciplinary care conference, a working diagnosis of ROHHAD syndrome was made based on the rapid onset of obesity, hypoventilation on sleep studies and CBGs, hypothalamic dysfunction, and autonomic degeneration. Workup for neural crest tumor with MRI chest and abdomen unremarkable. Outside academic consultation was sought for management which recommended shared decision-making regarding steroids, immunosuppressive therapy (eg rituximab, cyclophosphamide), and IVIG. Conclusion For ROHHAD syndrome, there are very few documented cases in the United States and there is no known laboratory marker; diagnosis remains clinical and takes multidisciplinary collaboration, education, and a high degree of suspicion. Support (if any)

BackgroundGlobally 70.8 million people have been forcibly displaced from their homes and are at disproportionally high risk for trauma. At the time of this study, there was an estimated 1.6 million internally displaced persons (IDP) in Iraq, more than two-thirds of whom reside in private, urban settings. This study aims to understand the impact of post-displacement accommodation on mental well-being of the Yazidi minority group displaced in Iraq.MethodsMulti-stage stratified sampling was used to randomly select IDPs in camp and out of camp settlements in northern Iraq. Standardized questionnaires evaluated factors including exposure to violence and self-reported distress symptoms (measured by Impact of Event Scale-Revised). A multi-variate linear model assessed the relationship between settlement setting and distress symptoms.ResultsOne thousand two hundred fifty-six displaced Yazidi participants were included in the study: 63% in camps and 37% out of camps. After controlling for exposure to violence, social cohesion, unemployment, and access to basic services, IDPs in camps were predicted to have a 19% higher mean distress symptom score compared to those out of camps.ConclusionsThis study provides a framework to investigate post-displacement accommodation as a potential intervention to improve well-being for displaced populations. With a shift towards new models of emergency and long-term housing, it is important to understand the potential and limitations of more decentralized models, and identify effective methods to maintain access to basic services while improving living conditions for both displaced populations and their host communities.

Disparities in preterm birth and neonatal mortality rates persist in Canada, in part as the result of insufficient training in newborn resuscitation and stabilization care, and inconsistent adherence to best practices. The Neonatal Resuscitation Program (NRP) has been the standard of care in all facilities providing perinatal care in Canada since the 1990s, but perinatal care providers and educators have continued to recognize gaps in knowledge and skill when stabilizing newborns post-resuscitation, especially in settings where this care is encountered infrequently. The Acute Care of at-Risk Newborns (ACoRN) program was developed to bridge such gaps. In ACoRN, an initial Primary Survey and systems-based care pathways (Sequences) prioritize and guide the assessment, essential care, and management of at-risk or unwell newborns in the first hours and days of life. This practice point highlights changes to practice and recommendations since 2012, when the ACoRN text and program were last revised. Like NRP, ACoRN is administered in Canada by the Canadian Paediatric Society (CPS). A newly revised and updated textbook and teaching program, both launched in 2021, will standardize care, increase competence and confidence among perinatal care providers, and improve neonatal outcomes in Canada and elsewhere in years to come.

Obstructive sleep apnea (OSA) is a multisystem breathing disorder associated with increased morbidity and mortality. Clinical and operative assessment tools improve surgical approaches to treat airway obstruction. The primary sites of anatomic obstruction are at the levels of the nasal, palatal, and hypopharyngeal airway. The literature suggests a relationship between reduced neuromuscular tone and the age-related increase in OSA prevalence for normal-weight adults. Pharyngeal soft tissue collapse due to reduced airway pressure is defined as the critical closing pressure. Respiratory biochemistry homeostasis is an additional factor in maintaining airway patency.

ALMA has been operating since 2011, but has not yet been populated with the full suite of intended frequency bands. In particular, ALMA Band 2 (67-90 GHz) is the final band in the original ALMA band definition to be approved for production. We aim to produce a wideband, tuneable, sideband-separating receiver with 28 GHz of instantaneous bandwidth per polarisation operating in the sky frequency range 67-116 GHz. Our design anticipates new ALMA requirements following the recommendations in the 2030 ALMA Development Roadmap. The cryogenic cartridge is designed to be compatible with the ALMA Band 2 cartridge slot, where the coldest components -- the feedhorns, orthomode transducers, and cryogenic low noise amplifiers -- operate at a temperature of 15 K. We use multiple simulation methods and tools to optimise our designs for both the passive optics and the active components. The cryogenic cartridge interfaces with a room temperature cartridge hosting the local oscillator (LO) and the downconverter module. This warm cartridge is largely based on GaAs semiconductor technology and is optimised to match the cryogenic receiver bandwidth with the required instantaneous LO tuning range. Our collaboration has designed, fabricated, and tested multiple technical solutions for each of the components, producing a state-of-the-art receiver covering the full ALMA Band 2 & 3 atmospheric window. The receiver is suitable for deployment on ALMA in the coming years, and is capable of dual-polarisation, sideband-separating observations in intermediate frequency bands spanning 4-18 GHz, for a total of 28 GHz on-sky bandwidth per polarisation channel. We conclude that the 67-116 GHz wideband implementation for ALMA Band 2 is now feasible, and this receiver is a compelling instrumental upgrade that will enhance observational capabilities and scientific reach., 23 pages, accepted for publication in A&A on 20 Dec 2019. This version corrects the affiliations of 2 co-authors

En pédiatrie, la prise de décision médicale est compliquée par les variations importantes du développement physique et psychologique observées entre la naissance et l’adolescence. Les parents et les tuteurs sont les décideurs de facto au nom des nourrissons, mais par la suite, leur rôle et celui des patients deviennent de plus en plus complexe. Tout au long de l’enfance, les dispensateurs de soins (DdS), qui ne sont pas des décideurs en soi, ont un rôle important à jouer dans la prise de décision médicale. Le présent document de principes expose les principes éthiques de la prise de décision médicale pour les DdS qui participent aux soins des patients pédiatriques. Cette mise à jour porte sur la prise de décision individuelle dans le cadre de la relation entre le patient et le DdS et fournit plus de conseils en cas de mésententes.

Medical decision-making in the paediatric population is complicated by the wide variation in physical and psychological development that occurs as children progress from infancy to adolescence. Parents and legal guardians are the de facto decision-makers in early infancy, but thereafter, the roles of parents/ legal guardians and paediatric patients become ever more complex. Health care providers (HCPs), while not decision-makers per se, have a significant role in medical decision-making throughout childhood. This statement outlines the ethical principles of medical decision-making for HCPs involved in caring for paediatric patients. This revision focuses on individual decision-making in the context of the patient–provider relationship and provides increased guidance for dealing with disagreements.

OBJECTIVES: Create trustworthy, rigorous, national clinical practice guidelines for the practice of pediatric donation after circulatory determination of death in Canada. METHODS: We followed a process of clinical practice guideline development based on World Health Organization and Canadian Medical Association methods. This included application of Grading of Recommendations Assessment, Development, and Evaluation methodology. Questions requiring recommendations were generated based on 1) 2006 Canadian donation after circulatory determination of death guidelines (not pediatric specific), 2) a multidisciplinary symposium of national and international pediatric donation after circulatory determination of death leaders, and 3) a scoping review of the pediatric donation after circulatory determination of death literature. Input from these sources drove drafting of actionable questions and Good Practice Statements, as defined by the Grading of Recommendations Assessment, Development, and Evaluation group. We performed additional literature reviews for all actionable questions. Evidence was assessed for quality using Grading of Recommendations Assessment, Development, and Evaluation and then formulated into evidence profiles that informed recommendations through the evidence-to-decision framework. Recommendations were revised through consensus among members of seven topic-specific working groups and finalized during meetings of working group leads and the planning committee. External review was provided by pediatric, critical care, and critical care nursing professional societies and patient partners. RESULTS: We generated 63 Good Practice Statements and seven Grading of Recommendations Assessment, Development, and Evaluation recommendations covering 1) ethics, consent, and withdrawal of life-sustaining therapy, 2) eligibility, 3) withdrawal of life-sustaining therapy practices, 4) ante and postmortem interventions, 5) death determination, 6) neonatal pediatric donation after circulatory determination of death, 7) cardiac and innovative pediatric donation after circulatory determination of death, and 8) implementation. For brevity, 48 Good Practice Statement and truncated justification are included in this summary report. The remaining recommendations, detailed methodology, full Grading of Recommendations Assessment, Development, and Evaluation tables, and expanded justifications are available in the full text report. CONCLUSIONS: This process showed that rigorous, transparent clinical practice guideline development is possible in the domain of pediatric deceased donation. Application of these recommendations will increase access to pediatric donation after circulatory determination of death across Canada and may serve as a model for future clinical practice guideline development in deceased donation.

Primary Subject area Neonatal-Perinatal Medicine Background Resuscitation care planning for extremely low gestational age neonates (ELGANs) continues to be one of the most complex, ethically charged areas within paediatrics. Objectives This study sought to determine the current attitudes and practices of neonatologists in Canada, and to assess the moral distress associated with resuscitation decisions in the ELGAN population and current practices in an era of improved neonatal outcomes. It also aimed to explore the perspectives of adopting a shared decision-making approach, where further data with regard to best interests and prognosis are gathered in an individualized manner. Design/Methods This was a descriptive study employing an electronic survey constructed in REDCap®. The survey was distributed to neonatologists working in Level III NICUs across Canada and responses were collected from March to May 2020. Results 65 total survey responses were received. 78% of neonatologists expressed at least some moral distress when parents request non-resuscitation between 24 weeks 0 days and 24 weeks 6 days. Prognostic uncertainty with regard to individualized long-term outcome in an era with increased chances of morbidity-free survival was the most prominent factor identified as contributing to moral distress. 70% felt they would feel less moral distress deciding about goals of care after assessing the baby’s response to an initial trial of resuscitation at birth, and preferred an individualized approach to palliation decisions based on postnatal course and assessment, rather than making the decision based primarily on gestational age. Conclusion While most current practices support the option of non-resuscitation for infants born at less than 25 weeks, there is growing evidence of moral distress among Canadian neonatologists that suggests the consideration of resuscitation at 24 weeks and above is a more realistic approach in the current era of improved outcomes. Furthermore, our results suggest that Canadian neonatologists are ethically more comfortable developing plans for care postnatally, with more evidence to support prognostication, instead of antenatally, based solely on gestational age.

To examine rates and determinants of mother's own milk (MOM) feeding at hospital discharge in a cohort of infants born very preterm within the Canadian Neonatal Network (CNN).This was a population-based cohort study of infants born at33 weeks of gestation and admitted to neonatal intensive care units (NICUs) participating in the CNN between January 1, 2015, and December 31, 2018. We examined the rates and determinants of MOM use at discharge home among the participating NICUs. We used multivariable logistic regression analysis to identify independent determinants of MOM feeding.Among the 6404 infants born very preterm and discharged home during the study period, 4457 (70%) received MOM or MOM supplemented with formula. Rates of MOM feeding at discharge varied from 49% to 87% across NICUs. Determinants associated with MOM feeding at discharge were gestational age 29-32 weeks compared with26 weeks (aOR 1.56, 95% CI 1.25-1.93), primipara mothers (aOR 2.12, 95% CI 1.86-2.42), maternal diabetes (aOR 0.79, 95% CI 0.66-0.93), and maternal smoking (aOR 0.27, 95% CI 0.19-0.38). Receipt of MOM by day 3 of age was the major predictor of breast milk feeding at discharge (aOR 3.61, 95% CI 3.17-4.12).Approximately two-thirds of infants born very preterm received MOM at hospital discharge, and rates varied across NICUs. Supporting mothers to provide breast milk in the first 3 days after birth may be associated with improved MOM feeding rates at discharge.

Background One of the controversies in the management of twin gestations relates to mode of delivery, especially when the second twin is in a nonvertex presentation (Vertex/nonVertex pairs) and birth is imminent at extremely low gestation. Objective We hypothesized that, for Vertex/nonVertex twins born before 28 weeks’ gestation, cesarean delivery would be associated with a lower risk of adverse neonatal outcomes than trial of vaginal delivery. Our aim was to test this hypothesis by comparing the neonatal outcomes of Vertex/nonVertex twins born before 28 weeks’ gestation by mode of delivery using a large national cohort. Study Design This work is a retrospective cohort study of all twin infants born at 240/7 to 276/7 weeks’ gestation and admitted to level III neonatal intensive care units participating in the Canadian Neonatal Network (2010–2017). Exposure is defined a trial of vaginal delivery for Vertex/nonVertex twins. Nonexposed (control) groups are defined as cases where both twins were delivered by cesarean delivery, either in vertex or nonvertex presentation (control group 1) or owing to the nonvertex presentation of the first twin (control group 2). Outcome measures are defined as a composite of neonatal death, severe neurologic injury, or birth trauma. Results A total of 1082 twin infants (541 twin pairs) met the inclusion criteria: 220 Vertex/nonVertex pairs, of which 112 had a trial of vaginal delivery (study group) and 108 had cesarean delivery for both twins (control group 1); 170 pairs with the first twin in nonvertex presentation, all of which were born by cesarean delivery (control group 2); and 151 pairs with both twins in vertex presentation (vertex or nonvertex). In the study group, the rate of urgent cesarean delivery for the second twin was 30%. The rate of the primary outcome in the study group was 42%, which was not significantly different compared with control group 1 (37%; adjusted relative risk, 0.93; 95% confidence interval, 0.71–1.22) or control group 2 (34%; adjusted relative risk, 1.20; 95% confidence interval, 0.92–1.58). The findings remained similar when outcomes were analyzed separately for the first and second twins. Conclusion For preterm Vertex/nonVertex twins born at

Objective The study's purpose was to assess efficacy of blended learning to decrease stress and burnout among nurses through use of the Stress Management and Resiliency Training (SMART) program. Background Job-related stress in nurses leads to high rates of burnout, compromises patient care, and costs US healthcare organizations billions of dollars annually. Many mindfulness and resiliency programs are taught in a format that limits nurses' attendance. Methods Consistent with blended learning, participants chose the format that met their learning styles and goals; Web-based, independent reading, facilitated discussions. The end points of mindfulness, resilience, anxiety, stress, happiness, and burnout were measured at baseline, postintervention, and 3-month follow-up to examine within-group differences. Results Findings showed statistically significant, clinically meaningful decreases in anxiety, stress, and burnout and increases in resilience, happiness, and mindfulness. Conclusions Results support blended learning using SMART as a strategy to increase access to resiliency training for nursing staff.

BACKGROUND AND OBJECTIVES: Hypoglycemia monitoring is not recommended for most full-term newborns. We wished to determine the incidence, presentation and case characteristics of hypoglycemia in low-risk newborns. METHODS: With the assistance of the Canadian Paediatric Surveillance Program, we conducted a national study of severe hypoglycemia in apparently low-risk full-term newborns. Paediatricians who reported a case were sent a detailed questionnaire and the data were analyzed. RESULTS: All 93 confirmed cases were singletons, 56% were first-borns and 65% were male. An 8% rate of First Nations cases was twofold the population rate. Maternal hypertension rate was 23%, fourfold the general pregnancy rate. Maternal obesity was double the general pregnancy rate at 23%. Concerning signs or feeding issues were noted in 98% at the time of diagnosis. Median time to diagnosis was 4.1 hours. Mean blood glucose at intravenous (IV) start was 1.4 ± 0.5 hours (SD). Seventy-eight per cent had at least one of four potential stress indicators and were more likely to have early diagnosis (P=0.03). Major signs were present in 20%. Those cases presented later and had lower glucose levels (median=0.8 mmol/L versus 1.6 mmol/L, [P

To compare mortality and neurodevelopmental outcomes of extremely low gestational age neonates who received delivery room extensive cardiopulmonary resuscitation (DR-CPR) to those who did not require DR-CPR.Preterm neonates born at29 weeks' gestational age between January 2010 and September 2011 and assessed at Canadian Neonatal Follow-Up Network centers were studied. Neonates who received DR-CPR were compared to those who did not require DR-CPR using univariate and multivariable analyses. The primary outcome was a composite of mortality or any neurodevelopmental impairment at 18 to 24 months corrected age defined as the presence of any one or more of the following: cerebral palsy; Bayley-III cognitive, language, or motor composite scores85 on any one of the components; sensorineural/mixed hearing loss or unilateral or bilateral visual impairment. Secondary outcomes were the individual components of the composite outcomes.Of the 2760 neonates born, 173 were excluded and remaining 2587 eligible neonates were included in our study. Of these 2068 had outcome data (80%) of whom 190 (9.2%) received DR-CPR. DR-CPR was independently associated with mortality or neurodevelopmental impairment (adjusted odds ratio [aOR] 1.76; 95% CI 1.21-2.55) and mortality alone (aOR1.94; 95% CI 1.33-2.83). DR-CPR was also associated with increased odds of motor impairment (aOR 2.03; 95% CI 1.28-3.23).In extremely low gestational age neonates, DR-CPR was associated with higher odds of the composite outcome of mortality or neurodevelopmental impairment, mortality alone, and lower motor scores at 18 to 24 months' corrected age.

Objective This study sought to determine the incidence and severity of respiratory morbidity among late preterm and term babies born by elective Caesarean section (CS) in London, Ontario. Methods A retrospective chart review was conducted of all elective CSs performed at or beyond 360 weeks gestation from June 2010 to June 2014 at London Health Sciences Centre and St. Joseph's Health Care (Canadian Task Force Classification II-2). Results The main indications for elective CS were previous CS (59.3%) and malpresentation (24.2%). The majority of elective CSs were performed at 38 weeks (34.1%) and 39 weeks (40.1%). Although only 3.7% of babies born by elective CS were found to have respiratory morbidity, 85% of these babies were admitted to the neonatal intensive care unit (NICU), and 15% required additional observation through a triage period. The relative risk of respiratory morbidity with elective CS at ≤386 weeks compared with ≥390 weeks was 2.14 (P = 0.0110). Only 3.5% of patients received antenatal steroids. There was an increased level of intervention among the babies admitted to the NICU for respiratory morbidity; 47.8%, 19.6%, 60.8%, and 15.25% required oxygen supplement, bag and mask, continuous positive airway pressure, and intubation with mechanical ventilation, respectively. Conclusion The risk of respiratory morbidity was significantly higher following elective CS before 39 weeks gestation. This resulted in increased length of stay and increased requirements for intravenous lines, blood draws, and exposure to antibiotics. This study provides further evidence that uncomplicated elective CS should be performed at ≥39 weeks, and interventions, such as preoperative antenatal steroid administration, may be considered if elective CS is medically indicated before 39 weeks.

Broadband refractive optics realized from high-index materials provide compelling design solutions for the next generation of observatories for the cosmic microwave background and for sub-millimeter astronomy. In this paper, work is presented which extends the state of the art in silicon lenses with metamaterial antireflection coatings toward larger-bandwidth and higher-frequency operation. Examples presented include octave bandwidth coatings with less than $$0.5\%$$ reflection, a prototype 4:1 bandwidth coating, and a coating optimized for 1.4 THz. For these coatings, the detailed design, fabrication and testing processes are described as well as the inherent performance trade-offs.

Background There is no consensus regarding approaches to infantile group B streptococcal (GBS) head and neck cellulitis and necrotizing fasciitis. We present a case of GBS necrotizing cellulitis and summarize the literature regarding the presentation and management of infantile head and neck GBS cellulitis and necrotizing fasciitis. Methods The literature was searched using PubMed, Web of Science, EMBASE and Medline (inception to April 2017) by 2 independent review authors. Inclusion criteria encompassed case reports or case series of infants less than 12 months of age with GBS cellulitis of the head and neck or with GBS necrotizing fasciitis without restriction to the head and neck. Data were extracted using tables developed a priori by 2 independent review authors, and discrepancies were resolved by consensus. Results An infant presenting at 33 days of age with GBS facial necrotizing fasciitis was successfully treated conservatively with antibiotics. Our literature search identified 40 infants with GBS head and neck cellulitis. Late-onset (98%), male gender (65%) and prematurity (58%) predominated. Penicillin is the main therapy used (97%). The 12 identified cases of necrotizing fasciitis were associated with polymicrobial etiology (36%) and broad-spectrum antibiotic use. Seventy-five percent required debridement, including 4 of 5 (80%) cases involving the head and neck. Conclusions Skin and soft tissue involvement is an uncommon manifestation of late-onset GBS infection which requires antibiotic therapy and possibly surgical debridement cases with necrotizing fasciitis.

The Simons Observatory (SO) will observe the temperature and polarization anisotropies of the cosmic microwave background (CMB) over a wide range of frequencies (27 to 270 GHz) and angular scales by using both small (∼0.5 m) and large (∼6 m) aperture telescopes. The SO small aperture telescopes will target degree angular scales where the primordial B-mode polarization signal is expected to peak. The incoming polarization signal of the small aperture telescopes will be modulated by a cryogenic, continuously-rotating half-wave plate (CRHWP) to mitigate systematic effects arising from slowly varying noise and detector pair-differencing. In this paper, we present an assessment of some systematic effects arising from using a CRHWP in the SO small aperture systems. We focus on systematic effects associated with structural properties of the HWP and effects arising when operating a HWP, including the amplitude of the HWP synchronous signal (HWPSS), and I → P (intensity to polarization) leakage that arises from detector non-linearity in the presence of a large HWPSS. We demonstrate our ability to simulate the impact of the aforementioned systematic effects in the time domain. This important step will inform mitigation strategies and design decisions to ensure that SO will meet its science goals.

Paediatric practitioners interact with industry representatives for many purposes but most often to receive information on new and existing products. While practitioners believe they are immune to the marketing influences exerted by these representatives, research has demonstrated otherwise. The literature suggests that the public is aware of such influences and that most people feel industry influence on practitioners is inappropriate. National guidelines go some way toward regulating practitioner–industry interactions, although they are not always clear or sufficient. The present practice point explores the context for these relationships, raises some ethical issues specific to paediatric practitioners and provides recommendations for maintaining professional integrity in the patient–physician relationship. Paediatric practitioners have a professional duty to ensure that their own interactions with industry are conducted with the best interests of the patient front and centre.

Les praticiens en pédiatrie interagissent avec des représentants de l’industrie pour bien des motifs, mais la plupart du temps, ils recherchent de l’information sur les nouveaux produits et ceux déjà existants. Ils se pensent à l’abri des influences publicitaires qu’exercent ces représentants, mais les recherches démontrent qu’il en est autrement. D’après les publications, la population est au courant de ces influences, et la plupart des gens les trouvent inappropriées. Les lignes directrices nationales contribuent jusqu’à un certain point à réglementer les interactions entre les praticiens et l’industrie, mais elles ne sont pas toujours claires ni suffisantes. Le présent point de pratique aborde le contexte de ces relations, soulève certains enjeux déontologiques propres aux praticiens en pédiatrie et contient des recommandations pour assurer le maintien de l’intégrité professionnelle dans le cadre de la relation entre le patient et le médecin. Dans leurs interactions avec l’industrie, les praticiens en pédiatrie ont le devoir professionnel de respecter, d’abord et avant tout, l’intérêt du patient.

Infrared (IR) blocking filters are crucial for controlling the radiative loading on cryogenic systems and for optimizing the sensitivity of bolometric detectors in the far-IR. We present a new IR filter approach based on a combination of patterned frequency selective structures on silicon and a thin (50 $\mu \textrm{m}$ thick) absorptive composite based on powdered reststrahlen absorbing materials. For a 300 K blackbody, this combination reflects $\sim$50\% of the incoming light and blocks \textgreater 99.8\% of the total power with negligible thermal gradients and excellent low frequency transmission. This allows for a reduction in the IR thermal loading to negligible levels in a single cold filter. These composite filters are fabricated on silicon substrates which provide excellent thermal transport laterally through the filter and ensure that the entire area of the absorptive filter stays near the bath temperature. A metamaterial antireflection coating cut into these substrates reduces in-band reflections to below 1\%, and the in-band absorption of the powder mix is below 1\% for signal bands below 750 GHz. This type of filter can be directly incorporated into silicon refractive optical elements.

We present a new measurement of the kinematic Sunyaev-Zeldovich effect using data from the Atacama Cosmology Telescope (ACT) and the Baryon Oscillation Spectroscopic Survey (BOSS). Using 600 square degrees of overlapping sky area, we evaluate the mean pairwise baryon momentum associated with the positions of 50,000 bright galaxies in the BOSS DR11 Large Scale Structure catalog. A non-zero signal arises from the large-scale motions of halos containing the sample galaxies. The data fits an analytical signal model well, with the optical depth to microwave photon scattering as a free parameter determining the overall signal amplitude. We estimate the covariance matrix of the mean pairwise momentum as a function of galaxy separation, using microwave sky simulations, jackknife evaluation, and bootstrap estimates. The most conservative simulation-based errors give signal-to-noise estimates between 3.6 and 4.1 for varying galaxy luminosity cuts. We discuss how the other error determinations can lead to higher signal-to-noise values, and consider the impact of several possible systematic errors. Estimates of the optical depth from the average thermal Sunyaev-Zeldovich signal at the sample galaxy positions are broadly consistent with those obtained from the mean pairwise momentum signal., 15 pages, 8 figures, 2 tables

We present the temperature and polarization angular power spectra measured by the Atacama Cosmology Telescope Polarimeter (ACTPol). We analyze night-time data collected during 2013-14 using two detector arrays at 149 GHz, from 548 deg$^2$ of sky on the celestial equator. We use these spectra, and the spectra measured with the MBAC camera on ACT from 2008-10, in combination with Planck and WMAP data to estimate cosmological parameters from the temperature, polarization, and temperature-polarization cross-correlations. We find the new ACTPol data to be consistent with the LCDM model. The ACTPol temperature-polarization cross-spectrum now provides stronger constraints on multiple parameters than the ACTPol temperature spectrum, including the baryon density, the acoustic peak angular scale, and the derived Hubble constant. Adding the new data to planck temperature data tightens the limits on damping tail parameters, for example reducing the joint uncertainty on the number of neutrino species and the primordial helium fraction by 20%., 23 pages, 25 figures

Objective: To increase our understanding of moral distress experienced by neonatal registered nurses when directly or indirectly involved in the decision-making process of resuscitating infants who are born extremely premature. Design: A secondary qualitative analysis was conducted on a portion of the data collected from an earlier study which explored the ethical decision-making process among health professionals and parents concerning resuscitation of extremely premature infants. Setting: A regional, tertiary academic referral hospital in Ontario offering a perinatal program. Participants: A total of 15 registered nurses were directly or indirectly involved in the resuscitation of extremely premature infants. Methods: Interview transcripts of nurses from the original study were purposefully selected from the original 42 transcripts of health professionals. Inductive content analysis was conducted to identify themes describing factors and situations contributing to moral distress experienced by nurses regarding resuscitation of extremely premature infants. Ethical considerations: Ethical approval was obtained from the research ethics review board for both the initial study and this secondary data analysis. Results: Five themes, uncertainty, questioning of informed consent, differing perspectives, perceptions of harm and suffering, and being with the family, contribute to the moral distress felt by nurses when exposed to neonatal resuscitation of extremely premature infants. An interesting finding was the nurses’ perceived lack of power and influence in the neonatal resuscitation decision-making process. Conclusion: Moral distress continues to be a significant issue for nursing practice, particularly among neonatal nurses. Strategies are needed to help mediate the moral distress experienced by nurses, such as debriefing sessions, effective communication, role clarification, and interprofessional education and collaboration.

Advanced ACTPol (AdvACT) is an upgraded camera for the Atacama Cosmology Telescope (ACT) that will measure the cosmic microwave background in temperature and polarization over a wide range of angular scales and five frequency bands from 28-230 GHz. AdvACT will employ four arrays of feedhorn-coupled, polarization- sensitive multichroic detectors. To accommodate the higher pixel packing densities necessary to achieve Ad- vACT's sensitivity goals, we have developed and optimized wideband spline-profiled feedhorns for the AdvACT multichroic arrays that maximize coupling efficiency while carefully controlling polarization systematics. We present the design, fabrication, and testing of wideband spline-profiled feedhorns for the multichroic arrays of AdvACT.

The Atacama Cosmology Telescope Polarimeter (ACTPol) is a polarization sensitive upgrade to the Atacama Cosmology Telescope. Located at an elevation of 5190 m, ACTPol measures the Cosmic Microwave Background (CMB) temperature and polarization with arcminute-scale angular resolution. Calibration of the detector angles is a critical step in producing maps of the CMB polarization. Polarization angle offsets in the detector calibration can cause leakage in polarization from E to B modes and induce a spurious signal in the EB and TB cross correlations, which eliminates our ability to measure potential cosmological sources of EB and TB signals, such as cosmic birefringence. We present our optical modeling and measurements associated with calibrating the detector angles in ACTPol., 12 pages, 8 figures, conference proceedings submitted to Proceedings of SPIE; added reference in section 2 and merged repeated reference

Advanced ACTPol is a polarization-sensitive upgrade for the 6 m aperture Atacama Cosmology Telescope (ACT), adding new frequencies and increasing sensitivity over the previous ACTPol receiver. In 2016, Advanced ACTPol will begin to map approximately half the sky in five frequency bands (28-230 GHz). Its maps of primary and secondary cosmic microwave background (CMB) anisotropies -- imaged in intensity and polarization at few arcminute-scale resolution -- will enable precision cosmological constraints and also a wide array of cross-correlation science that probes the expansion history of the universe and the growth of structure via gravitational collapse. To accomplish these scientific goals, the Advanced ACTPol receiver will be a significant upgrade to the ACTPol receiver, including four new multichroic arrays of cryogenic, feedhorn-coupled AlMn transition edge sensor (TES) polarimeters (fabricated on 150 mm diameter wafers); a system of continuously rotating meta-material silicon half-wave plates; and a new multiplexing readout architecture which uses superconducting quantum interference devices (SQUIDs) and time division to achieve a 64-row multiplexing factor. Here we present the status and scientific goals of the Advanced ACTPol instrument, emphasizing the design and implementation of the Advanced ACTPol cryogenic detector arrays., 9 pages, 3 figures, conference proceedings submitted to Journal of Low Temperature Physics

Across Canada, the rate of preterm birth (i.e., at < 37 weeks’ gestation) has been steadily increasing. Advances in perinatal medicine and neonatal intensive care have resulted in an increased capacity to intervene at the extremes of prematurity, leading to an increase in the overall survival of infants born at early gestations. There has been little corresponding decrease in long-term complications. As a result, additional stresses are placed on neonatal intensive care units across the country, impacting families, health care professionals, and society as a whole. Moral distress and moral residue are often cited in the neonatal–perinatal literature as stressors experienced by those who participate in the resuscitation decision-making process. They are directly related to the challenge of making a concrete decision about life and death at extremely early gestations in the context of longterm uncertainty. In this review, we performed a systematic search of medical and ethics literature pertaining to resuscitation at the extremes of prematurity. The perspective of health care professionals is explored, including how definitions of viability and parental perspectives contribute to the decision-making process. We argue for the necessity of further research exploring the inter-professional context of ethical decision making at the extremes of prematurity. Au Canada, le taux d’accouchement préterme (c.-à-d. à < 37 semaines de gestation) connaît une hausse constante. Les percées dans les domaines de la médecine périnatale et des soins intensifs néonatals ont eu pour effet d’accroître la capacité d’intervenir aux extrêmes de la prématurité, ce qui a mené à une hausse du taux global de survie des enfants nés à la suite d’une gestation écourtée. En parallèle, nous n’avons constaté qu’une faible baisse du taux de complication à long terme. Par conséquent, des pressions additionnelles sont imposées aux unités néonatales de soins intensifs de partout au pays, affectant ainsi les familles, les professionnels de la santé et la société dans son ensemble. La détresse morale et des reliquats moraux sont souvent cités dans la littérature néonatale-périnatale parmi les facteurs de stress connus par ceux qui participent au processus décisionnel entourant la réanimation. Ils sont directement liés au défi de la prise de décisions concrètes concernant la vie ou la mort dans le cas des gestations extrêmement précoces, dans le contexte d’une incertitude pour ce qui est du long terme. Dans le cadre de cette analyse, nous avons mené une recherche systématique dans la littérature médicale et éthique portant sur la réanimation aux extrêmes de la prématurité. Le point de vue des professionnels de la santé est exploré, y compris la façon dont les définitions de viabilité et les points de vue parentaux contribuent au processus décisionnel. Nous soulignons la nécessité d’approfondir la recherche explorant le contexte interprofessionnel de la prise de décision éthique aux extrêmes de la prématurité.

We present the design and the preliminary on sky performance with respect to beams and pass-bands of a multichroic polarimeter array covering the 90 and 146 GHz Cosmic Microwave Background (CMB) bands and its enabling broadband optical system recently deployed on the Atacama Cosmology Telescope (ACT). The constituent pixels are feedhorn-coupled multichroic polarimeters fabricated at NIST. This array is coupled to the ACT telescope via a set of three silicon lenses incorporating novel broad-band metamaterial anti-reflection coatings. This receiver represents the first multichroic detector array deployed for a CMB experiment and paves the way for the extensive use of multichroic detectors and broadband optical systems in the next generation of CMB experiments.

We present a measurement of the gravitational lensing of the Cosmic Microwave Background (CMB) temperature and polarization fields obtained by cross-correlating the reconstructed convergence signal from the first season of ACTPol data at 146 GHz with Cosmic Infrared Background (CIB) fluctuations measured using the Planck satellite. Using an overlap area of 206 square degrees, we detect gravitational lensing of the CMB polarization by large-scale structure at a statistical significance of 4.5 sigma. Combining both CMB temperature and polarization data gives a lensing detection at 9.1 sigma significance. A B-mode polarization lensing signal is present with a significance of 3.2 sigma. We also present the first measurement of CMB lensing--CIB correlation at small scales corresponding to l > 2000. Null tests and systematic checks show that our results are not significantly biased by astrophysical or instrumental systematic effects, including Galactic dust. Fitting our measurements to the best-fit lensing-CIB cross power spectrum measured in Planck data, scaled by an amplitude A, gives A=1.02 +0.12/-0.18 (stat.) +/-0.06(syst.), consistent with the Planck results., Submitted to ApJ

We present evidence of the gravitational lensing of the cosmic microwave background by $10^{13}$ solar mass dark matter halos. Lensing convergence maps from the Atacama Cosmology Telescope Polarimeter (ACTPol) are stacked at the positions of around 12,000 optically-selected CMASS galaxies from the SDSS-III/BOSS survey. The mean lensing signal is consistent with simulated dark matter halo profiles, and is favored over a null signal at 3.2 sigma significance. This result demonstrates the potential of microwave background lensing to probe the dark matter distribution in galaxy group and galaxy cluster halos., 9 pages, 3 figures, accepted by PRL, author list corrected

The use of blogs, Facebook and similar social networking sites is rapidly expanding and, when compared with e-mail, may be having a significantly different impact on the traditional doctor-patient relationship. Characteristics specific to these online platforms have major implications for professional relationships, including the ‘Facebook effect’ (the relative permanence of postings) and the ‘online disinhibition effect’. The present practice point illustrates relevant ethical considerations and provides guidance to paediatricians and others concerning the prudent professional and personal use of social networking media. L’utilisation des blogues, de Facebook et de sites de réseautage social similaires prend une expansion rapide. Par rapport aux courriels, les réseaux sociaux peuvent avoir des répercussions très différentes sur la relation classique entre le médecin et son patient. Les caractéristiques propres à ces plateformes virtuelles ont des conséquences considérables sur les relations professionnelles, y compris « l’effet Facebook » (la permanence relative des textes affichés) et « l’effet de désinhibition virtuelle ». Le présent point de pratique illustre les considérations éthiques pertinentes et oriente les pédiatres et les autres professionnels de la santé quant à l’utilisation professionnelle et personnelle prudente des réseaux sociaux.

The purpose of this study was to identify supplementary criteria to provide direction when the Ontario Health Plan for an Influenza Pandemic (OHPIP) critical care triage protocol is rendered insufficient by its inability to discriminate among patients assessed as urgent, and there are insufficient critical care resources available to treat those in that category. To accomplish this task, a Supplementary Criteria Task Force for Critical Care Triage was struck at the University of Toronto Joint Centre for Bioethics. The task force reviewed publically available protocols and policies on pandemic flu planning, identified 13 potential triage criteria and determined a set of eight key ethical, legal and practical considerations against which it assessed each criterion. An online questionnaire was distributed to clinical, policy and community stakeholders across Canada to obtain feedback on the 13 potential triage criteria toward selecting those that best met the eight considerations. The task force concluded that the balance of arguments favoured only two of the 13 criteria it had identified for consideration: first come, first served and random selection. The two criteria were chosen in part based on a need to balance the clearly utilitarian approach employed in the OHPIP with equity considerations. These criteria serve as a defensible "fail safe" mechanism for any triage protocol.

We report on measurements of the cosmic microwave background (CMB) and celestial polarization at 146 GHz made with the Atacama Cosmology Telescope Polarimeter (ACTPol) in its first three months of observing. Four regions of sky covering a total of 270 square degrees were mapped with an angular resolution of $1.3'$. The map noise levels in the four regions are between 11 and 17 $\mu$K-arcmin. We present TT, TE, EE, TB, EB, and BB power spectra from three of these regions. The observed E-mode polarization power spectrum, displaying six acoustic peaks in the range $200, Comment: 16 pages, 15 figures, 5 tables