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Inducible laryngeal obstruction (ILO) in children is underrecognized. This systematic review characterizes the scientific evidence on the impact of pediatric ILO diagnosis and treatment on asthma medication use. This review, registered with PROSPERO (CRD42020209168), utilized database searches in MEDLINE, EMBASE, CINAHL, and Web of Science from inception to October 2020. Both experimental and observational studies on ILO and asthma outcomes in patients ≤18 years were included. Population characteristics (sample size, sex, age, and comorbidities) and study outcomes (medication usage and respiratory symptoms) were extracted. The risk of bias was assessed with the National Toxicology Program's Office of Health Assessment and Risk of Bias Rating Tool. Data are presented narratively due to study heterogeneity. Of 1091 studies, 1076 titles and abstracts were screened after duplicate removal. Screening 31 full texts yielded eight pre-post studies. Patients were an average of 14.1 years old, 15% male, and90% used asthma medication; 40% reported allergies, 30% gastroesophageal reflux, and 20% anxiety or depression. Most patients received at least one intervention, with 75% showing symptomatic improvement and75% decreasing or stopping asthma medications. Studies were small with a high risk of selection, confounding, and detection bias. Asthma management was not a primary outcome in any of the studies. Overall, ILO patients were often diagnosed with or treated for asthma before ILO diagnosis. Evidence from individual studies suggests that comorbidities including ILO, gastroesophageal reflux, allergies, and anxiety should be considered in pediatric patients with asthma not responsive to medical therapy. Further research is required to determine the proportion of impacted asthma patients.

The assessment of systemic blood flow is a complex and comprehensive process with clinical, laboratory, and technological components. Despite recent advancements in technology, there is no perfect bedside tool to quantify systemic blood flow in infants that can be used for clinical decision making. Each option has its own merits and limitations, and evidence on the reliability of these physiology-based assessment processes is evolving. This article provides an extensive review of the interpretation and limitations of methods to assess systemic blood flow in infants, highlighting the importance of a comprehensive and multimodal approach in this population.

Secondhand smoke (SHS) exposure increases the prevalence and severity of sinopulmonary diseases in children. The primary source of SHS exposure in children is through adults who live in the same house; however, the level of exposure may vary based on the adult smoking habits at home. This prospective cross-sectional study in Alberta, Canada, investigated the relationship between self-reported caregiver smoking, location, outdoor temperature and children’s’ urine cotinine: creatinine ratio (CCR), a marker of nicotine metabolism. Participants aged 0–9 were recruited from the Child Health Clinics at the Misericordia Community Hospital in Edmonton, Alberta, from 8 January to 24 February 2016 and 30 June to 18 August 2016. Participant CCR levels were compared to caregiver-reported smoking location and environmental factors such as temperature and season. Of the 233 participants who reported smoking status, 21% reported smoking, in keeping with local smoking rates. More participants smoked indoors during the winter than the summer; however, some families limited indoor smoking to a garage. Of the 133 parent–child dyads who provided smoking information and a child urine sample, 18 had an elevated cotinine:creatinine ratio, suggestive of significant tobacco smoke exposure, 15 of whom were from homes that reported smoking. Age < 1 year and number of cigarettes smoked in the home weekly were risks for significant exposure while season, outdoor temperature and smoking location in the home did not reach significance. Smokers should be counseled to protect children, particularly infants, from exposure by limiting the number of cigarettes smoked and isolating smoking to outside the home. Segregated areas such as a garage may provide a useful harm mitigation strategy for indoor smokers, provided the garage does not share ventilation or is not in close proximity to high-traffic areas of the home.

Objective: To investigate the incidence and risk factors of retinopathy of prematurity (ROP) in very and extremely preterm (28+0

A previous large US study had documented an increased risk of asphyxia in small volume and rural hospitals. Our objective was to evaluate this in all hospitals in Alberta, a Canadian province.Retrospective cohort study of all singleton births ≥ 35-week gestation, in Alberta, from 2002-16 recorded in a perinatal database. Asphyxia was defined as intrapartum stillbirth or neonatal death from asphyxia or Neonatal Intensive Care Unit admission and at least two of the following: a. Apgar score of ≤ 5 at 10 minutes; b. mechanical ventilation or chest compressions for resuscitation within 10 minutes; c. cord pH 7.00 (venous or arterial), or arterial base excess ≥ 12 at birth. Urban hospitals were defined as those serving a population of ≥ 50 000. Hospital volume was categorized by the following: urban: 1200, 1200-2399, 2400-3600, 3600 annual births and Rural: 50, 50-599, 600-1699 annual births. Data on moderate-severe neonatal hypoxic-ischemic encephalopathy was also obtained from two provincial asphyxia databases for 2010-2016.The overall rate of neonatal asphyxia was 2.28 per 1000 births for the study period and was 2.5/1000 in the urban hospitals and 1.35/1000 in the rural hospitals, OR: 1.86 95% CI (1.58, 2.19). The rate of moderate or severe neonatal hypoxic-ischemic encephalopathy was 0.9/1000 and was not associated with urban hospital birth; OR: 1.12 95%CI (0.82, 1.53) hospital volume was also not associated with asphyxia or moderate or severe neonatal hypoxic-ischemic encephalopathy.This study observed similar rates of asphyxia and moderate or severe neonatal hypoxic-ischemic encephalopathy for rural and urban hospitals in Alberta and no association with hospital volume.

A 43-year-old Asian American man with asthma and hypertension was referred to the movement disorder center with a 5-year history of gradually progressive action-induced ankle inversion followed by trunk tightness and painful neck twisting with right shoulder elevation. He was born in the United States and successfully graduated college as a B/C student with mild learning difficulties. He always had disproportionally long limbs and digits and at age 12 developed ectopia lentis (medial-inferior displacement). Numerous ocular surgeries were performed including intraocular lens exchange with iris fixation. Marfan syndrome was previously diagnosed based on physical findings. There was no family history of Marfan syndrome, marfanoid features, or early death due to aortic dissection. FBN1 mutations were not tested and serial echocardiograms demonstrated no aortic root dilation. Diagnosis was later refined to ectopia lentis syndrome per updated guidelines. At age 29, he required allograft repair of an anterior cruciate ligament following minor impact. Four years later, while walking, he had musculoskeletal trauma in the left foot with subsequent toe extension weakness. Nerve conduction studies confirmed absence of compound motor action potentials in the left peroneal nerve lateral terminal branch. At age 38, he developed left foot pain with tendency for dorsiflexion and ankle inversion when walking. Severity gradually progressed and tightness extended to the trunk within 2 years. At age 41, he developed elevation of the right shoulder and several weeks later rightward rotation of the neck and back. Dystonia gradually progressed. Symptoms were exacerbated by stress but not relieved by alcohol or muscle relaxers.

Background Despite multiple published guidelines outlining the potential health risks caused by tobacco smoke, young children continue to be exposed to the detrimental effects of household smoking. Environmental factors also have the potential to influence levels of tobacco exposure in children. Many factors such as comfort can influence the decisions of smoking parents to smoke indoors, increasing potential harm for children. Understanding the correlation between various locations within the household and tobacco exposure is helpful in informing a harm reduction strategy for smokers. This project compared the location of reported tobacco use to detection of the nicotine byproduct cotinine in children’s urine samples. Objectives To determine the impact of smoking location on unintentional tobacco exposure in children. Design/Methods This prospective cross-sectional study focused on children under age ten, since 13% of Canadian children in grades 6 and up have tried a cigarette at least once. Of 286 parents approached during a pediatrician visit, 231 agreed to complete an exposure questionnaire and 132 children were able to provide a urine sample during the visit. A standard ELISA assay was used to measure urine cotinine. Results About half of the 31% of households that reported smoking had an indoor smoking ban. Some indoor smokers isolated their activity to the garage (56%). Of the 84 children with detectable urine cotinine, 62 lived in homes that reported smoking. This suggests that some children were exposed to tobacco smoke through other sources or the underestimation of potential tobacco exposure. Fifteen percent of children from smoking homes had cotinine levels similar to nonsmoking homes. Children of indoor smokers were more likely to have detectable cotinine than those of outdoor smokers. Conclusion Roughly 50% of smokers with children have an indoor smoking ban as a harm reduction strategy. In our study, children of smokers with an indoor smoking ban were less likely to have detectable urine cotinine. Although not smoking is the best strategy, limiting smoking to outside is an optimal harm mitigation strategy. For families with indoor smokers, encouraging them to isolate smoking to a single space like the garage may decrease unintentional pediatric exposure.

We developed a novel secured web-based dystonia video repository for the Dystonia Coalition, part of the Rare Disease Clinical Research network funded by the Office of Rare Diseases Research and the National Institute of Neurological Disorders and Stroke. A critical component of phenotypic data collection for all projects of the Dystonia Coalition includes a standardized video of each participant. We now describe our method for collecting, serving and securing these videos that is widely applicable to other studies.Each recruiting site uploads standardized videos to a centralized secured server for processing to permit website posting. The streaming technology used to view the videos from the website does not allow downloading of video files. With appropriate institutional review board approval and agreement with the hosting institution, users can search and view selected videos on the website using customizable, permissions-based access that maintains security yet facilitates research and quality control.This approach provides a convenient platform for researchers across institutions to evaluate and analyze shared video data. We have applied this methodology for quality control, confirmation of diagnoses, validation of rating scales, and implementation of new research projects.We believe our system can be a model for similar projects that require access to common video resources.

To determine the pre-conception practices among obstetrician-gynaecologists and family physicians in Canada.Between October 2001 and May 2002, a survey was mailed to a national random sample of obstetricians and gynaecologists (n = 539) and family physicians (n = 2378) who were current members of the College of Family Physicians of Canada or the Society of Obstetricians and Gynaecologists of Canada.Response rates were 41.7% among obstetrician-gynaecologists and 31.1% among family physicians. More than 85% of physicians frequently discussed birth control and Pap testing with women of childbearing age, but fewer than 60% frequently obtained a detailed history of alcohol use. Fewer than 50% of physicians frequently discussed the following with women of childbearing age: weight management, workplace stress, mental health, addiction history, or the risks of substance use during pregnancy. Fewer than 15% enquired about a history of sexual or emotional abuse. Family physicians were significantly more likely than obstetrician-gynaecologists to discuss mental health (41.1% vs. 28.1%), depression (44.5% vs. 29.0%), and history of alcohol use (59.8% vs. 47.9%) with women of childbearing age (all P0.05). Obstetrician-gynaecologists were significantly more likely than family physicians to discuss folic acid (57.8% vs. 47.2%), sexual abuse (18.2% vs. 10.8%), smoking (56.0% vs. 46.1%), and drug use (45.8% vs. 35.9%) (all P0.05) with women of childbearing age who were not pregnant.There are missed opportunities in pre-conception screening to identify women with suboptimal reproductive health status who are at risk for adverse conception, pregnancy, and birth outcomes. Physician training in identification of women at risk would allow for increased primary and secondary prevention efforts through referral to appropriate treatment and resources.

Retaining guardianship of one's infant is often a priority for pregnant women who use substances, and may be beneficial to infants when they are safe in their mothers' care. Previous studies from the United States have identified several maternal psychosocial characteristics associated with the ability to keep an infant free from abuse or neglect; however, little is known about the impact of multiple risk factors on guardianship, particularly in Canadian intervention programs.To describe maternal characteristics associated with child guardianship among pregnant women at risk of an alcohol and/or substance exposed pregnancy who attended a Canadian home visitation program.Guardianship status at 6 months post-enrolment was extracted from a provincial program's records for all women enrolled between November 1999 and May 2005 (n=64). Bivariate analyses were performed to determine client characteristics most likely to have retained guardianship.At follow-up, 70% of participants were guardians of the index infant. Higher income, more prenatal care, no history of sexual abuse, better alcohol and psychiatric scores, and fewer risk factors on a cumulative risk index were significantly associated with retaining guardianship at 6 month follow-up (p0.05).Retaining child guardianship may be the greatest challenge and opportunity for women experiencing problems in multiple domains of their lives, including those associated with substance dependence. Programs targeted at women who use substances while pregnant may best assist mothers to retain guardianship of their infants by supporting clients to address the complex social and health problems often found in conjunction with addictions.

Fetal alcohol spectrum disorders (FASDs) are the most common form of nongenetic birth defect in North America with devastating, long-term consequences. Physicians are the primary providers of medical care for pregnant women and they play an important role in the prevention and diagnosis of FASD. We sought to determine whether differences exist between rural and urban health care providers in knowledge of, attitudes about and awareness of FASD and preconception counselling.Surveys were mailed to a national, random sample of Canadian health care providers (n = 5361) between October 2001 and May 2002. Bivariate data analysis was completed using SPSS 14.0.Compared with their urban counterparts, rural providers were more likely to report being prepared to access resources related to alcohol use and dependency, yet they were less likely to agree that it was the physician's role to manage these issues (78.4% v. 82.8%, p0.05). Rural providers were more likely than urban providers to use a standardized tool to screen patients for alcohol use, to ask all pregnant women if they were drinking, to have cared for a patient with an FASD (56.7% v. 48.8%), to agree that providers do not make a diagnosis because of lack of time and training, and to recognize legal issues and inappropriate behaviour as secondary outcomes of FASD. Rural and urban providers were similar in their diagnostic knowledge of FASD.Few differences between rural and urban providers exist with regard to knowledge and diagnosis of FASD; however, rural providers are more prepared to access resources for women with addiction issues and are more likely to care for patients with an FASD.

The purpose of this study was to determine if triplet infants with birthweight < or = 1250 g were at increased risk of long-term disability compared with similar birthweight and gestational age singletons and twins. This was a retrospective cohort study of < or = 1250-g infants admitted to a regional neonatal intensive care unit from 1986 to 2001 with follow-up to 36 to 48 months corrected gestational age. Outcomes studied were cognitive ability, cerebral palsy, and neurosensory impairment at 36 to 48 months. Enrollment was 1717 infants: 59 triplets, 402 twins, and 1256 singletons. Triplet infants differed from twin or singleton infants because they were more likely to have older, married mothers (relative risk [RR] 3.62, 95% CI 1.31, 5.94), be products of assisted reproductive technology pregnancies (RR 29.59, 95% CI 13.97, 62.68), be exposed to antenatal steroids (RR 1.55, 95% CI 1.38, 1.75), and were all delivered by cesarean section. Triplet infants had lower risk of having intraventricular hemorrhage (RR 0.19, 95% CI 0.05, 0.75). The risk of cerebral palsy, cognitive delay, total major disability, or chronic lung disease was similar in triplet and twin infants compared with singleton infants. The lower risk of having intraventricular hemorrhage in triplet infants may have been due to the use of antenatal corticosteroids and cesarean section delivery.

Active modulators using pulse transformers are an option for pulsing magnetrons. In this context, active implies a single or a number of paralleled or a number of series connected or a series/parallel combination of semiconductor switches used to pulse a magnetron via a step up pulse transformer. The pulse is delivered by a large capacitor bank (pulse energy is very much less than the capacitor stored energy) and the switches must be of a type that can be turned both on and off such as MOSFETs or IGBTs. A problem can arise because of the biased diode nature of the magnetron load (typically a magnetron that works at 20 kV/20 A will draw very little current at 16 kV, ref figure 1). Thus when the active switches are turned off the current pulse in the magnetron is terminated. The stray capacitance on the output of the pulse transformer however remains charged to almost full voltage. This can give rise to a complex series of events which can damage the active switches. This paper will carefully define the problem and describe a solution.

Women rely on health care providers for general health care and preconception counseling, including advice on alcohol consumption. Definitions of moderate consumption may differ by individual provider, resulting in inconsistency in advice and lack of clarity for patients both before and during pregnancy. The objective of this study was to determine if health care providers' definition of moderate alcohol consumption was associated with advice to pregnant women regarding alcohol use during pregnancy and to describe health care providers' communication regarding alcohol consumption. Between October 2001 and October 2002, a survey was mailed to a national random sample of 3114 Canadian obstetricians and gynecologists, midwives, and family physicians. The main outcome measure was questionnaire responses regarding knowledge and prevention issues related to alcohol and pregnancy as well as provider characteristics. Response rates ranged from 31.1% among family physicians to 63.5% among midwives. Moderate alcohol consumption among nonpregnant women was defined as 1 to 2 drinks per occasion by about 89% of providers and did not relate to recommendations during pregnancy. Those who recommended abstinence during pregnancy were more likely to define moderation as 4 or more occasions per week as compared with those who did not recommend abstinence (P=0.022). Fewer than 50% of providers frequently defined "moderation" for their patients. More family physicians (90.0%) than obstetricians (83.9%) or midwives (81.1%) recommended alcohol abstinence during pregnancy (overall 87.8%, P=0.005). Thus, there is opportunity for providers to appropriately counsel their patients by advising alcohol abstinence during pregnancy and more frequently defining "moderation" for all clients.

Objective: National initiatives on fetal alcohol syndrome in Canada and the United States aimed at prevention, identification, and treatment of individuals who are affected by alcohol exposure in utero recommend that women abstain from consuming alcohol during pregnancy. Health care providers are key educators regarding appropriate alcohol use. The objective of this study was to describe characteristics of physicians who recommend alcohol abstinence during pregnancy with regard to knowledge of fetal alcohol syndrome and preconception counseling strategies. Methods: A survey was mailed to Canadian physicians and midwives between 2001 and 2002. Participants consisted of a national random sample of 1090 Canadian obstetricians and gynecologists, midwives, and family physicians who were current members of provincial and national professional organizations. The main outcome measure was questionnaire responses to knowledge, prevention, and diagnosis of issues related to alcohol use during pregnancy. Results: Response rates ranged from 31.1% among family physicians to 63.5% among midwives. Overall, 91.2% of providers recommended abstinence from alcohol during pregnancy. These providers were significantly more likely to believe that there is sufficient information about alcohol use and that clients were interested in discussing alcohol (p < 0.05). They were also significantly more likely to discuss depression, personal alcohol use, partner's use of alcohol, and family history of alcohol misuse with women of childbearing age (p < 0.05). Once a patient became pregnant, fewer practice differences were noted, although those who recommended alcohol abstinence were significantly more likely to take clinical action when pregnant patients were consuming moderate amounts of alcohol (p < 0.05). Conclusions: It is encouraging that almost 90% of Canadian health care providers recommend abstinence from alcohol during pregnancy. However, differences in clinical practice exist between providers who recommend alcohol abstinence during pregnancy as compared with those who recommend a “glass in moderation.”

Background Developmental and language outcomes at 2 years of age of children who had arterial switch operation (ASO) for transposition of the great arteries 2004–2010 are described. Methods In this prospective cohort study, 91/98 (93 %) children who underwent ASO were assessed at 2 years of age with the Bayley Scales of Infant & Toddler Development—3rd Edition. Outcomes were compared by patient and perioperative variables using bivariate and multivariate regression analyses to identify predictors of language delay. Results Infants without ventricular septal defect (VSD) (n = 60) were more likely to be outborn (73 vs 58 %, p = 0.038), require septostomy (80 vs 58 %, p = 0.026), have a shorter cross clamp time (min) (62.7 vs 73.0, p = 0.019), and a lower day 1 post-operative plasma lactate (mmol/L) (3.9 vs 4.8, p = 0.010). There were no differences in cognitive, motor and language outcomes based on presence of a VSD. Language delay (