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Interscalene brachial plexus block is the standard regional analgesic technique for shoulder surgery. Given its adverse effects, alternative techniques have been explored. Reports suggest that the erector spinae plane block may potentially provide effective analgesia following shoulder surgery. However, its analgesic efficacy for shoulder surgery compared with placebo or local anaesthetic infiltration has never been established. We conducted a randomised controlled trial to compare the analgesic efficacy of pre-operative T2 erector spinae plane block with peri-articular infiltration at the end of surgery. Sixty-two patients undergoing arthroscopic shoulder repair were randomly assigned to receive active erector spinae plane block with saline peri-articular injection (n = 31) or active peri-articular injection with saline erector spinae plane block (n = 31) in a blinded double-dummy design. Primary outcome was resting pain score in recovery. Secondary outcomes included pain scores with movement; opioid use; patient satisfaction; adverse effects in hospital; and outcomes at 24 h and 1 month. There was no difference in pain scores in recovery, with a median difference (95%CI) of 0.6 (-1.9-3.1), p = 0.65. Median postoperative oral morphine equivalent utilisation was significantly higher in the erector spinae plane group (21 mg vs. 12 mg; p = 0.028). Itching was observed in 10% of patients who received erector spinae plane block and there was no difference in the incidence of significant nausea and vomiting. Patient satisfaction scores, and pain scores and opioid use at 24 h were similar. At 1 month, six (peri-articular injection) and eight (erector spinae plane block) patients reported persistent pain. Erector spinae plane block was not superior to peri-articular injection for arthroscopic shoulder surgery.

Patients with adolescent idiopathic scoliosis undergoing corrective surgery are at risk for iatrogenic spinal cord injury and subsequent new neurologic deficits (NNDs). Intraoperative neurophysiologic monitoring (IONM) has been used to identify spinal cord injury; however, available data showing that IONM leads to improved clinical outcomes are inconclusive. This exploratory study aimed to examine the incidence of NNDs after idiopathic scoliosis surgery in two pediatric institutions in Canada with a focus on IONM use.Charts of pediatric patients (10-18 yr) with adolescent idiopathic scoliosis who underwent scoliosis correction surgery were retrospectively identified from the operating room database. Data regarding incidence and severity (mild [isolated sensory deficit] vs severe [any motor deficit]) of NNDs as well as demographic and clinical characteristics were extracted.Of 547 patients reviewed, 359 (66%) underwent IONM and 186 (34%) underwent wake-up test. Neuromonitoring data were missing in two patients. Total incidence of NNDs was 4.9% (95% confidence interval [CI], 3.1 to 6.8). Compared with the wake-up test, patients undergoing IONM were less likely to develop NNDs (unadjusted odds ratio, 0.39; 95% CI, 0.18 to 0.86; P = 0.02). Nevertheless, subgroup analysis did not reveal a statistical difference in severity of those deficits (mild vs severe) with IONM vs wake-up test. Combined anterior and posterior approach was also significantly associated with increased risk of such deficits.This exploratory study revealed that IONM was associated with a reduced overall incidence of NNDs in idiopathic scoliosis correction; however, its impact on the severity of those deficits is questionable. As we were unable to adjust for confounding variables, further research is needed to determine the impact of IONM on NNDs.RéSUMé: OBJECTIF: Les patients adolescents atteints de scoliose idiopathique subissant une chirurgie corrective sont à risque de lésions médullaires iatrogéniques et de nouveaux déficits neurologiques (NDN) subséquents. Le monitorage neurophysiologique peropératoire (MNP) a été employé pour identifier les lésions médullaires; cependant, les données disponibles montrant que le MNP entraîne de meilleurs pronostics cliniques ne sont pas concluantes. Cette étude exploratoire visait à examiner l’incidence des NDN après une chirurgie de scoliose idiopathique dans deux établissements pédiatriques au Canada en se concentrant sur l’utilisation du MNP. MéTHODE: Les dossiers des patients pédiatriques (10-18 ans) atteints de scoliose idiopathique ayant subi une chirurgie de correction de scoliose ont été rétrospectivement identifiés dans la base de données de salle d’opération. Les données concernant l’incidence et la gravité (légers [déficit sensoriel isolé] vs graves [tout déficit moteur]) des NDN ainsi que les caractéristiques démographiques et cliniques ont été extraites. RéSULTATS: Parmi les 547 patients passés en revue, 359 (66 %) ont eu un MNP et 186 (34 %) ont eu un test d’éveil (‘wake-up test’). Les données de monitorage neurologique manquaient pour deux patients. L’incidence totale des NDN était de 4,9 % (intervalle de confiance [IC] de 95 %, 3,1 à 6,8). Par rapport au test d’éveil, les patients subissant un MNP étaient moins susceptibles de présenter des NDN (rapport de cotes non ajusté, 0,39; IC 95 %, 0,18 à 0,86; P = 0,02). Néanmoins, l’analyse des sous-groupes n’a pas révélé de différence statistique dans la gravité de ces déficits (légers vs graves) en comparant un MNP à un test d’éveil. Une association significative a également été relevée entre une approche combinée chirurgicale antérieure et postérieure et un risque accru de tels déficits. CONCLUSION: Cette étude exploratoire a indiqué que le MNP était associé à une incidence globale réduite de NDN lors d’une chirurgie de correction de scoliose idiopathique; toutefois, son impact sur la gravité de ces déficits est discutable. Comme nous n’avons pas été en mesure d’ajuster les données aux variables confondantes, d’autres recherches sont nécessaires pour déterminer l’impact du MNP sur les NDN.

Opioids are the most widely used therapy for pain during the postoperative period. It has been suggested by some that hydromorphone is clinically superior. Our primary objective was to determine if there is a difference in postoperative pain score ratings between adult patients receiving intravenous hydromorphone vs intravenous morphine on discharge from the post-anesthesia care unit (PACU).For this historical cohort study, convenience sampling was used to identify the first 605 patients ≥ 18 yr undergoing elective, non-cardiac surgery. Patients were categorized based on treatment in the PACU with hydromorphone (n = 326) or morphine (n = 279). Pain scores (scale of 0-10), nausea/vomiting (scale of 0-3), pruritis (scale of 0-3), and sedation (scale of 0-4), as well as total opioid dose administered from arrival in the PACU until readiness to discharge were evaluated.For the primary outcome of pain reported at discharge from the PACU, there was no significant difference between the mean (standard deviation) hydromorphone numeric rating scale (NRS) [2.8 (1.6)] and the morphine NRS [2.5 (1.5)] after adjusting for potential confounders (adjusted mean difference, 0.10; 95% confidence interval, -0.21 to 0.42; P = 0.53). Similarly, there were no significant between-group differences in length of stay in the PACU, satisfactory analgesia, nausea/vomiting, and sedation.This study serves to help guide the decision-making process for selecting either morphine or hydromorphone for acute postoperative analgesia. Overall, we found no significant difference for analgesia or for common opioid-related adverse effects between these two opioids in the postoperative period at the time of discharge from the PACU. Furthermore, according to this data, the equipotency ratio of hydromorphone to morphine is closer to 1:6.5 rather than the commonly employed 1:5 ratio.RéSUMé: OBJECTIF: Les opioïdes sont le traitement le plus fréquemment utilisé pour prendre en charge la douleur postopératoire. Certains auteurs suggèrent que l’hydromorphone est supérieure d’un point de vue clinique. Notre objectif principal était de déterminer s’il existait une différence dans les scores de douleur postopératoire entre des patients adultes ayant reçu de l’hydromorphone intraveineuse comparativement à de la morphine intraveineuse lors de leur congé de la salle de réveil. MéTHODE: Pour cette étude de cohorte historique, un échantillonnage de commodité a été utilisé pour identifier les premiers 605 patients ≥ 18 ans subissant une chirurgie non cardiaque non urgente. Les patients ont été catégorisés en fonction du traitement reçu à la salle de réveil, soit hydromorphone (n = 326) ou morphine (n = 279). Les scores de douleur (échelle de 0-10), les nausées et vomissements (échelle de 0-3), le prurit (échelle de 0-3) et la sédation (échelle de 0-4), ainsi que la dose totale d’opioïdes administrés entre l’arrivée en salle de réveil et le moment de recevoir le congé ont été évalués. RéSULTATS: En ce qui touche à notre critère d’évaluation principal de douleur rapportée au moment du congé de la salle de réveil, aucune différence significative n’a été observée entre le score moyen (écart type) de l’hydromorphone sur l’échelle d’évaluation numérique (EEN) [2,8 (1,6)] et celui de la morphine [2,5 (1,5)] après avoir ajusté les valeurs pour tenir compte des facteurs de confusion potentiels (différence moyenne ajustée, 0,10; intervalle de confiance 95 %, -0,21 à 0,42; P = 0,53). De la même manière, aucune différence intergroupe significative n’a été observée en matière de durée de séjour à la salle de réveil, d’analgésie satisfaisante, de nausées et vomissements, et de sédation. CONCLUSION: Cette étude sert à guider le processus de prise de décision lors du choix de la morphine ou de l’hydromorphone pour l’analgésie postopératoire aiguë. Globalement, nous n’avons observé aucune différence significative dans l’analgésie procurée ou les effets secondaires néfastes liés aux opioïdes entre ces deux molécules en période postopératoire au moment du congé de la salle de réveil. En outre, selon ces données, le ratio d’efficacité équivalente de l’hydromorphone par rapport à la morphine est plus proche de 1:6,5 que du ratio fréquemment utilisé de 1:5.

End-of-life (EOL) care is a key aspect of critical care medicine (CCM) training. The goal of this study was to survey CCM residents and program directors (PDs) across Canada to describe current EOL care education. Using a literature review, we created a self-administered survey encompassing 10 CCM national objectives of training to address: (1) curricular content and evaluation methods, (2) residents’ preparedness to meet these objectives, and (3) opportunities for educational improvement. We performed pilot testing and clinical sensibility testing, then distributed it to all residents and PDs across the 13 Canadian CCM programs. Our response rate was 84.3% overall (77 [81.1%] for residents and 13 [100%] for PDs). Residents rated direct observation, informal advice, and self-reflection as both the top 3 most utilized and perceived most effective teaching modalities. Residents most commonly reported comfort with skills related to pain and symptom management (n = 67, 94.3%; score > 3 on 5-point Likert scale), and least commonly reported comfort with donation after cardiac death skills (n = 26-38; 44.8%-65.5%). Base specialty and time in CCM training were independently associated with comfort ratings for some, but not all, EOL skills. With respect to family meetings, residents infrequently received feedback; however, most PDs believed feedback on 6 to 10 meetings is required for competence. When PD perceptions of teaching effectiveness were compared with resident comfort ratings, differences were most apparent for skills related to pain and symptom management, cultural awareness, and ethical principles. By the end of their first subspecialty training year, PDs expect residents to be competent at most, but not all, EOL skills. In summary, trainees and programs rely on clinical activities to develop competency in EOL care, resulting in some educational gaps. Transitioning to competency-based medical education presents an opportunity to address some of these gaps, while other gaps will require more specific curricular intervention.

Objectives Bronchiolitis is the most common viral lower respiratory tract infection in children under age 2 for which high-flow nasal cannula (HFNC) is increasingly used. Understanding factors associated with HFNC failure is important to identify patients at risk for respiratory deterioration. The objective of this study was to evaluate patient characteristics associated with HFNC failure in bronchiolitis. Methods A retrospective review of patients aged 0 to 24 months, with bronchiolitis who received HFNC within a single tertiary paediatric intensive care unit, between January 2014 and December 2018 was conducted. HFNC treatment failure was defined as escalation to non-invasive positive pressure or invasive mechanical ventilation. Multivariable regression analysis was used to identify demographic, clinical, and biochemical parameters associated with HFNC failure. Results Two hundred eight patients met inclusion criteria, of which 61 (29.33%) failed HFNC. Risk factors for HFNC failure included younger age (odds ratio [OR] 1.12; 95% confidence interval [CI] 1.03, 1.23; P=0.011) and a Modified Tal score greater than 5 at 4 hours of HFNC therapy (OR 2.81; 95% CI 1.04, 7.64; P=0.042). Duration of HFNC in hours was protective (OR 0.94; 95% CI 0.92, 0.96; P Conclusion This is the first study exploring predictors of HFNC failure among Canadian children with bronchiolitis. Patient age, HFNC duration, and Modified Tal score were associated with HFNC failure. These factors should be considered when initiating HFNC for bronchiolitis to identify patients at risk for deterioration.

The use of interventional pain management (IPM) modalities to alleviate chronic pain is increasing despite the lack of high-quality evidence. We undertook this survey to explore patterns, training, and attributes of IPM practice. We administered a 32-item survey via seven Canadian physician member organizations, whose members were engaged in the management of chronic pain. Of 777 physicians contacted, 256 (33%) responded: 45 (6%) declined to participate and 211 (27%) agreed to participate; the number of participants answering any given question varied. One hundred and sixty-nine of 194 (87%) practiced IPM and 103 of 194 (53%) managed only non-cancer pain. Pain management training of ≥ six months was associated with higher odds of IPM training (odds ratio [OR], 2.98; 95% confidence interval [CI], 1.32 to 6.7), but not necessarily ongoing IPM practice (OR, 1.97; 95% CI, 0.74 to 5.3). A substantial percentage of physicians (108 of 168 [64%]) practiced IPM based only on training received during either their base residency program or courses. Only 48 of 186 (26%) felt that there were adequate opportunities for IPM training, and 69 of 186 (37%) believed that their colleagues practiced IPM in accordance with the best current evidence. Our survey indicates that IPM practice and training were not uniform, and that interventional therapies for chronic pain may not be performed in accordance with the best available evidence. Our survey highlights a lack of IPM training opportunities, which may result in substandard training. Concerted efforts involving physician organizations and regulators are needed to standardize IPM training and develop clinical guidelines to optimize evidence-based practice.

We compared secondary attack rates in households with B.1.1.7 variant of concern (VOC) versus non-VOC index cases in a matched cohort in Ontario, Canada. The secondary attack rate for VOC index cases was 1.31 times higher than non-VOC index cases. This increase was particularly accentuated for asymptomatic or presymptomatic index cases.

Educators detect and intervene in a small proportion of bullying incidents. Although students are present when many bullying episodes occur, they are often reluctant to intervene. This study explored attributes of antibullying (AB) programs influencing the decision to intervene. Grade 5, 6, 7, and 8 students (

IMPORTANCEHigher secondary attack rates related to variant of concern (VOC) index cases have been reported, but have not been explored within households, which continue to be an important source of coronavirus disease 2019 (COVID-19) transmissionOBJECTIVETo compare secondary attack rates in households with VOC versus non-VOC index cases.DESIGNA retrospective cohort study of household index cases reported from February 7 – 27, 2021. A propensity-score matched cohort was derived to calculate adjusted estimates.SETTINGOntario, Canada.PARTICIPANTSA population-based cohort of all private households with index cases. We excluded cases in congregate settings, as well as households with one individual or with >1 case with the same earliest symptom onset date.EXPOSUREVOC status, defined as either individuals confirmed as B.1.1.7 using whole genome sequencing or those that screened positive for the N501Y mutation using real-time PCR.MAIN OUTCOME AND MEASUREHousehold secondary attack rate, defined as the number of household secondary cases that occurred 1-14 days after the index case divided by the total number of household secondary contacts.RESULTSWe included 1,259 index VOC and non-VOC cases in the propensity score-matched analysis. The secondary attack rate for VOC index cases in this matched cohort was 1.31 times higher than non-VOC index cases (RR=1.31, 95%CI 1.14-1.49), similar to the unadjusted estimate. In stratified analyses, the higher secondary attack rate for VOC compared to non-VOC index cases was accentuated for asymptomatic index cases (RR=1.91, 95% CI 0.96-3.80) and presymptomatic cases (RR=3.41, 95%CI 1.13-10.26)CONCLUSIONS AND RELEVANCEThis study provides strong evidence of increased transmissibility in households due to VOCs and suggests that asymptomatic and pre-symptomatic transmission may be of particular importance for VOCs. Our study suggests that more aggressive public health measures will be needed to control VOCs and that ongoing research is needed to understand mechanisms of VOC transmissibility to curb their associated morbidity and mortality.

Background Intrathecal analgesia (IA) has been recommended by the Enhanced Recovery After Surgery (ERAS) Society for laparoscopic colon resections; however, although IA is used in open liver resections, it has not been extensively studied in laparoscopic hepatobiliary surgery. This retrospective chart review was undertaken to explore postoperative pain within 48 hours among patients who underwent laparoscopic liver resections (LLR), receiving either IA with or without patient-controlled analgesia (IA±PCA) versus PCA alone. Methods After ethics approval, charts were reviewed for adult patients who underwent LLR between January 2016 and April 2019, and had IA±PCA or PCA alone. Patients with any contraindication to IA with morphine, obstructive sleep apnea, body mass index >40 kg/m2, history of chronic pain, and/or history of drug use were excluded. Descriptive statistics used to describe postoperative pain levels at 48 hours by treatment group for each pain outcome. Results Of 111 patients identified, 79 patients were finally included; 22 patients had IA±PCA and 57 patients had PCA only. There were no statistically significant differences in baseline characteristics, use of non-opioid pain control, and postoperative complications between the two groups. IA use was associated with reduced postoperative opioid consumption (measured in oral morphine equivalents) compared to PCA alone (mean difference [95% confidence interval] -45.92 [-83.10 to -8.75]; p=0.016). Conclusions IA has the potential to decrease postoperative opioid use for patients undergoing LLR, and appears to be safe and effective in the setting of LLR. These findings are consistent with the ERAS Society recommendations for laparoscopic colorectal surgery.

Additional file 2: Appendix 2 Appendix_Calculation of group sample size. A supplementary document that presents the data for sample size estimates for the main trial (primary outcome, cumulative opioid consumption at 24 h).

Background The optimal analgesia method in video-assisted thoracoscopic surgery (VATS) remains controversial. Intercostal nerve blockade (ICNB) is limited by its duration of action. The erector spinae plane (ESP) block has the potential to provide satisfactory analgesia for VATS; however, the effectiveness of continuous ESP versus surgeon-performed ICNB has not been investigated. The objectives of this study were to establish feasibility of patient recruitment and follow-up before undertaking a fully powered randomized controlled trial (RCT); and, secondarily, to compare opioid usage, pain control, and sensory blockade. Methods This feasibility RCT was undertaken at St Joseph’s Hospital, Hamilton, Ontario, Canada, and included 24 patients (>18 years) having elective VATS with at least one overnight stay. Exclusion criteria were patient refusal, body mass index >40 kg/m2, contraindications to neuraxial analgesia techniques as per the American Society of Regional Anesthesia and Pain guidelines, known allergy to local anesthetics, language or comprehension barriers, procedures with a higher chance of open surgery, and regular opioid use for ≥3 months preoperatively. Patients underwent either continuous ESP (n=12) or surgeon-performed ICNB (n=12). All patients received routine intraoperative anesthesia care and multimodal analgesia. Feasibility criteria were recruitment rate of two patients/week and full follow-up in all patients in-hospital. We compared opioid consumption, postoperative pain scores (0–10 numerical rating scale), adverse events, patient satisfaction, and distribution of sensory blockade as clinical outcomes (secondary). Results Feasibility of primary outcomes was successfully demonstrated. Five patients had an epidural in anticipation of open surgery. Mean opioid consumption as equivalent morphine units was less in the ESP group over the first 24 h (mean difference, 1.63 [95% CI –1.20 to 4.45]) and 48 h (mean difference, 2.34 [95% CI –1.93 to 6.61]). There were no differences in adverse effects. Conclusions A fully powered RCT is feasible with modifications. Our results also suggest that continuous ESP is safe and can decrease opioid needs. However, it is important to consider procedures to improve compliance to protocol and adherence to assigned interventions. Trial registration Clinicaltrials.gov identifier: NCT03176667. Registered June 5, 2017.

Background Bronchiolitis is the most common viral lower respiratory tract infection in children under two years of age and is the leading cause of hospital admission for children under the age of one year. Respiratory support for bronchiolitis with high flow nasal cannula (HFNC) is increasingly being used outside of critical care areas and in community hospitals. It is important to understand the patient factors associated with HFNC treatment failure in order to identify which patients are at higher risk for requiring escalation of respiratory support and transfer to a pediatric critical care centre. Objectives The primary objective of this study was to evaluate the patient characteristics that are associated with HFNC treatment failure in bronchiolitis. Design/Methods We completed a retrospective review of patients under 24 months of age with a clinical diagnosis of bronchiolitis admitted to a single tertiary level children’s hospital for supportive management with HFNC between January 2014 and December 2018. Patients who were mechanically ventilated or on non-invasive positive pressure ventilation prior to the initiation of HFNC during their hospital stay were excluded. HFNC treatment failure was the primary endpoint of the study, with treatment failure defined as escalation to non-invasive positive pressure or invasive mechanical ventilation. Multivariable logistic regression analysis was used to identify the patient demographic, clinical, and biochemical parameters associated with HFNC failure. Results Four hundred and thirty-five patient charts were identified, of which 208 patients met inclusion criteria for the study. Of these patients, 61 (29%) were classified as HFNC treatment failures. The likelihood of failing HFNC support was reduced with older age (OR 0.89; 95% CI 0.81, 0.97; p= 0.011) and greater time spent on HFNC (OR 0.94; 95% CI 0.92, 0.96; p Conclusion This was the first study to examine predictors of HFNC failure among Canadian children with bronchiolitis. We found that patient age, time spent on HFNC, and severity of bronchiolitis as defined using a Modified Tal score were associated with HFNC failure. These patient factors should be considered when initiating HFNC for bronchiolitis, and may identify patients at risk for escalation of respiratory support, warranting earlier referral to pediatric critical care centres.

We used a discrete choice conjoint experiment to model the anti-bullying (AB) program preferences of 1080 junior kindergarten to Grade 8 educators. Participants chose between hypothetical AB programs that varied combinations of 12 design attributes. Multi-level latent class analysis yielded three classes: All-in Supervisors (21.5%) preferred that all teaching staff supervise playgrounds and hallways; Facilitators (61.6%) preferred that students take ownership of AB activities with 25% of educators supervising playgrounds and hallways; and Reluctant Delegators (16.9%) preferred delegating the supervision of playgrounds and hallways to non-teaching staff. This class reported higher dispositional reactance, more implementation barriers, and more psychological reactance to these initiatives. They were less sensitive to social influences and less intent on participating in AB activities. Multi-level analysis showed a greater proportion of Reluctant Delegators clustered in one of the two groups of schools. The program choices of all classes were sensitive to the support of principals, colleagues, students, and, to a lesser extent, parents. All classes preferred programs conducted from kindergarten through Grade 12 that addressed the problems underlying bullying while valuing firm and consistent consequences for all students. Educators preferred AB programs selected by individual schools, rather than governments. Electronic supplementary material The online version of this article (10.1007/s12310-019-09334-0) contains supplementary material, which is available to authorized users.

Supplement_2_-_Resident_and_Program_Director_Surveys for End-of-Life Skills and Professionalism for Critical Care Residents in Training: The ESPRIT Survey by Samantha Arora, Sameer Shaikh, Tim Karachi, Thuva Vanniyasingam, John Centofanti, Dominique Piquette, Maureen Meade, Anne Boyle, Anne Woods, James Downar and Deborah Cook in Journal of Intensive Care Medicine

Supplemental Material, Appendix_A_-_Raw_Survey_Data_-_Resident_Survey_Questions_and_Responses_2 for End-of-Life Skills and Professionalism for Critical Care Residents in Training: The ESPRIT Survey by Samantha Arora, Sameer Shaikh, Tim Karachi, Thuva Vanniyasingam, John Centofanti, Dominique Piquette, Maureen Meade, Anne Boyle, Anne Woods, James Downar and Deborah Cook in Journal of Intensive Care Medicine

Supplemental Material, Appendix_B_-_Raw_Survey_Data_-_Program_Director_Survey_Questions_and_Responses_1 for End-of-Life Skills and Professionalism for Critical Care Residents in Training: The ESPRIT Survey by Samantha Arora, Sameer Shaikh, Tim Karachi, Thuva Vanniyasingam, John Centofanti, Dominique Piquette, Maureen Meade, Anne Boyle, Anne Woods, James Downar and Deborah Cook in Journal of Intensive Care Medicine

Objective To describe current stress ulcer prophylaxis practice in Canadian PICUs. Design Multicenter cohort study. We defined stress ulcer prophylaxis as the use of a proton-pump inhibitor, histamine-2 receptor antagonist, or sucralfate within the first 2 PICU days among children who had not been on these medications at home and had no evidence of gastrointestinal bleeding. Setting Seven PICUs in Canada. Patients Three hundred seventy-eight children requiring mechanical ventilation. Interventions None. Measurements and main results Children were ventilated for a median (interquartile range) of 2 days (1-6 d) and stayed in the PICU for a median (interquartile range) of 4 days (2-10 d). The median (interquartile range) age was 1.3 years (0.3-6.7 yr). Seventy percent of all children received acid suppression during their PICU stay. One hundred sixty-seven (54%) of the 309 children eligible for stress ulcer prophylaxis received it. Histamine-2 receptor antagonists were the most frequently used class (66%), followed by proton-pump inhibitors (47%) and sucralfate (4%), and 20% received more than one class. Stress ulcer prophylaxis was continued on the PICU transfer orders for 34% of these children. Children who received prophylaxis were older and had a higher Pediatric Risk of Mortality III score, more often received nonsteroidal anti-inflammatory drugs and systemic corticosteroids and received less enteral nutrition. In multivariate analysis, age and invasive mechanical ventilation were independently associated with an increased likelihood of receiving stress ulcer prophylaxis and receiving feeds was independently associated with a decreased likelihood of receiving stress ulcer prophylaxis. Gastrointestinal bleeding was reported in 21 (6%) of 378 children; three (0.8%) were clinically important. Eighteen percent were treated for a new respiratory tract infection, and 1% developed Clostridium difficile-associated diarrhea. Conclusions Stress ulcer prophylaxis is common in Canadian PICUs. Clinically important gastrointestinal bleeding and C. difficile-associated diarrhea are rare, and the utility of routine prophylaxis should be examined.

Objectives: This study reviews simulation studies of discrete choice experiments to determine (i) how survey design features affect statistical efficiency, (ii) and to appraise their reporting quality. Outcomes: Statistical efficiency was measured using relative design (D-) efficiency, D-optimality, or D-error. Methods: For this systematic survey, we searched Journal Storage (JSTOR), Since Direct, PubMed, and OVID which included a search within EMBASE. Searches were conducted up to year 2016 for simulation studies investigating the impact of DCE design features on statistical efficiency. Studies were screened and data were extracted independently and in duplicate. Results for each included study were summarized by design characteristic. Previously developed criteria for reporting quality of simulation studies were also adapted and applied to each included study. Results: Of 371 potentially relevant studies, 9 were found to be eligible, with several varying in study objectives. Statistical efficiency improved when increasing the number of choice tasks or alternatives; decreasing the number of attributes, attribute levels; using an unrestricted continuous “manipulator” attribute; using model-based approaches with covariates incorporating response behaviour; using sampling approaches that incorporate previous knowledge of response behaviour; incorporating heterogeneity in a model-based design; correctly specifying Bayesian priors; minimizing parameter prior variances; and using an appropriate method to create the DCE design for the research question. The simulation studies performed well in terms of reporting quality. Improvement is needed in regards to clearly specifying study objectives, number of failures, random number generators, starting seeds, and the software used. Conclusion: These results identify the best approaches to structure a DCE. An investigator can manipulate design characteristics to help reduce response burden and increase statistical efficiency. Since studies varied in their objectives, conclusions were made on several design characteristics, however, the validity of each conclusion was limited. Further research should be conducted to explore all conclusions in various design settings and scenarios. Additional reviews to explore other statistical efficiency outcomes and databases can also be performed to enhance the conclusions identified from this review. Keywords: Discrete choice experiment, Systematic survey, Statistical efficiency, Relative D-efficiency, Relative D-error

Diabetes is often poorly managed in hospitals. This study assessed the level of adherence to current Canadian practice guidelines for inpatient pharmacologic management of type 2 diabetes and whether it affected the frequency of hyperglycemia or hypoglycemia.Retrospectively, we assessed the first 3 days of routine inpatient capillary blood glucose measurement (CBGM) records for hyperglycemia (8 mmol/L fasting,10 mmol/L nonfasting) and hypoglycemia (4 mmol/L) in adults with drug-treated type 2 diabetes admitted to internal medicine without metabolic decompensation or nil per os (NPO) status at 2 hospitals during October through December 2014. Patients, divided according to their admission orders into guideline-adherent versus guideline-nonadherent groups were compared for frequency of hyperglycemia and hypoglycemia. Factors predicting guideline adherence were assessed.Of 150 patients with diabetes who were admitted, 108 met entry criteria. A total of 89 patients received guideline-based care (82%), whereas 19 patients did not (18%). Charlson index and preadmission medications did not predict guideline-based care, but admitting physicians' seniority did (junior, senior resident, attending physician; p=0.05). In the adherent group, 43% of CBGMs were hyperglycemic, versus 64% in the nonadherent group (p=0.01). For hypoglycemia, proportions were 2% versus 1%, respectively (p=0.21).Adherence to guidelines for inpatient type 2 diabetes management is good and may be greater with more training. Hyperglycemia was more common in patients who did not receive guideline-based care. Hypoglycemia was uncommon and did not appear to be more common in the guideline-adherent group, although numbers were small. These results may alleviate physicians' fear that providing adequate insulin to hospitalized patients may cause hypoglycemia.

Objectives The primary objective of this systematic survey was to examine the percentage of studies in which there was agreement in the reporting of the primary outcome between the currently updated version of the clinical trial registry and the published paper. We also investigated the factors associated with agreement in reporting of the primary outcome. Methods We searched PubMed for all randomized control trials (RCT)s published in 2012–2015 in the top five general medicine journals (based on the 2014 impact factor). Two hundred abstracts (50 from each year) were randomly selected for data extraction. Agreement in reporting of 11 key study conduct items (e.g., sample size) and study characteristics (e.g., funding, number of sites) were extracted by two independent reviewers. Analysis Descriptive analyses were conducted to determine the proportion of studies on which there was agreement in reporting of key study conduct items. Generalized estimating equations were used to explore factors associated with agreement in reporting of the primary outcome. Results Of the 200 included studies, 87% had agreement in reporting of the primary outcome. After adjusting for other covariates, having greater than 50 sites was associated with an increased likelihood of agreement in reporting of the primary outcome (odds ratio = 7.1, 95% confidence interval = 1.39, 36.27, p = 0.018). Conclusions We identified substantive disagreement in reporting between publications and current clinical trial registry, which were associated with several study characteristics. Further measures are needed to improve reporting given the potential threats to the quality and integrity of scientific research.

Background Community-acquired pneumonia (CAP) is a common occurrence in childhood; consequently, evidence-based recommendations for its treatment are required. The study objective was to determine if, in previously healthy children presenting to the emergency department (ED), 5 days of high-dose amoxicillin led to noninferior rates of clinical cure at 14–21 days post-enrolment compared with 10 days of high-dose amoxicillin. Methods The SAFER study was a multicentre, randomized, parallel-group, multiple-blinded, controlled, noninferiority study, enrolling between 2012–2014 (single centre pilot) and then 2016–2019 (follow-up main study). Children aged 6 months – 10 years with all of the following were eligible: fever within 48h; a respiratory symptom/sign; a chest radiograph consistent with pneumonia as per the emergency MD; and a primary diagnosis of CAP. Children were excluded if they required hospitalization, had any medical comorbidities, or if they were already receiving beta-lactam antibiotic therapy. The intervention of interest was 5 days of high-dose amoxicillin followed by 5 days placebo. The control (standard care) arm received 5 days of high-dose amoxicillin followed by a different formulation of 5 days of high-dose amoxicillin. The primary outcome was clinical cure at 14–21 days post-enrolment. The pre-set noninferiority margin was 0.075 less than the clinical cure risk difference (1-sided 97.5% CI). Results Of the 281 participants, 119 (42%) were female; the median age was 2.6 y (25–75%ile 1.6–4.9 y). There were 140 randomized to short-course treatment and 141 to standard care. Clinical cure at 14–21 days was observed in 108/126 (86%) in the short-course arm and in 106/126 (84%) in the standard-care arm (risk difference 0.023, lower limit of 1-sided 97.5%CI -0.061). There were no participants who, after finishing amoxicillin, later deteriorated and required hospitalization for progressive CAP. Conclusion Short-course antibiotic therapy was noninferior to standard care for the treatment of previously healthy children with non-severe CAP diagnosed in Canadian EDs. Clinical practice guidelines should recommend no more than 5 days of amoxicillin for paediatric pneumonia management, in accordance with antimicrobial stewardship principles. Disclosures All Authors: No reported disclosures

Roux-en-Y gastric bypass (RYGB) is associated with the remission of type 2 diabetes mellitus (DM). There are a number of scoring systems available that help predict type 2 diabetes remission rates after bariatric surgery; however, relatively few have been validated externally. The DiaRem score, comprised of four preoperative variables (age, haemoglobin A1c [HbA1c], sulfonylurea and insulin-sensitizing agent use and insulin use), allows for the identification of patients who are most likely to have DM remission following RYGB. Our primary objective was to determine the variables predictive of DM remission 1 year post-RYGB, determine how well the DiaRem score predicts DM remission 1 year post-RYGB and identify the optimal cut-off DiaRem score. The study is based on results of RYGB performed across multiple centres in Ontario, Canada, overseen by the Centre for Surgical Invention and Innovation in Hamilton, with direction from the Ontario Bariatric Network. Regression analysis was used to determine the predictive value of demographic and clinical variables and that of the DiaRem score. The optimal DiaRem cut-off score was determined using sensitivity and specificity analysis. Of 3874 patients in the Ontario Bariatric Registry between January 2010 and February 2015, 915 had complete 1-year follow-up data. Among these, 15 were not classified as having DM at baseline and were excluded. Of the remaining 900 patients with type 2 diabetes and who underwent RYGB surgery, 333 (37.0%) had DM remission at 1-year follow-up. Three of four DiaRem variables (age, HbA1c, insulin use), in addition to use of any hypoglycaemic agent, were associated with DM remission. DiaRem score had moderate predictive value. A DiaRem score cut-off of

BACKGROUND Research has shown that introducing electronic Health (eHealth) patient monitoring interventions can improve healthcare efficiency and clinical outcomes. The VIGILANCE (VItal siGns monItoring with continuous puLse oximetry And wireless cliNiCian notification aftEr surgery) study was a randomized controlled trial (n=2049) designed to assess the impact of continuous vital sign monitoring with alerts sent to nursing staff when respiratory resuscitations with naloxone, code blues, and intensive care unit transfers occurred in a cohort of postsurgical patients in a ward setting. This report identifies and evaluates key issues and challenges associated with introducing wireless monitoring systems into complex hospital infrastructure during the VIGILANCE eHealth intervention implementation. Potential solutions and suggestions for future implementation research are presented. OBJECTIVE The goals of this study were to: (1) identify issues related to the deployment of the eHealth intervention system of the VIGILANCE study; and (2) evaluate the influence of these issues on intervention adoption. METHODS During the VIGILANCE study, issues affecting the implementation of the eHealth intervention were documented on case report forms, alarm event forms, and a nursing user feedback questionnaire. These data were collated by the research and nursing personnel and submitted to the research coordinator. In this evaluation report, the clinical adoption framework was used as a guide to organize the identified issues and evaluate their impact. RESULTS Using the clinical adoption framework, we identified issues within the framework dimensions of people, organization, and implementation at the meso level, as well as standards and funding issues at the macro level. Key issues included: nursing workflow changes with blank alarm forms (24/1030, 2.33%) and missing alarm forms (236/1030, 22.91%), patient withdrawal (110/1030, 10.68%), wireless network connectivity, false alarms (318/1030, 30.87%), monitor malfunction (36/1030, 3.49%), probe issues (16/1030, 1.55%), and wireless network standards. At the micro level, these issues affected the quality of the service in terms of support provided, the quality of the information yielded by the monitors, and the functionality, reliability, and performance of the monitoring system. As a result, these issues impacted access through the decreased ability of nurses to make complete use of the monitors, impacted care quality of the trial intervention through decreased effectiveness, and impacted productivity through interference in the coordination of care, thus decreasing clinical adoption of the monitoring system. CONCLUSIONS Patient monitoring with eHealth technology in surgical wards has the potential to improve patient outcomes. However, proper planning that includes engagement of front-line nurses, installation of appropriate wireless network infrastructure, and use of comfortable cableless devices is required to maximize the potential of eHealth monitoring. CLINICALTRIAL ClinicalTrials.gov NCT02907255; https://clinicaltrials.gov/ct2/show/NCT02907255

Background Research has shown that introducing electronic Health (eHealth) patient monitoring interventions can improve healthcare efficiency and clinical outcomes. The VIGILANCE (VItal siGns monItoring with continuous puLse oximetry And wireless cliNiCian notification aftEr surgery) study was a randomized controlled trial (n=2049) designed to assess the impact of continuous vital sign monitoring with alerts sent to nursing staff when respiratory resuscitations with naloxone, code blues, and intensive care unit transfers occurred in a cohort of postsurgical patients in a ward setting. This report identifies and evaluates key issues and challenges associated with introducing wireless monitoring systems into complex hospital infrastructure during the VIGILANCE eHealth intervention implementation. Potential solutions and suggestions for future implementation research are presented. Objective The goals of this study were to: (1) identify issues related to the deployment of the eHealth intervention system of the VIGILANCE study; and (2) evaluate the influence of these issues on intervention adoption. Methods During the VIGILANCE study, issues affecting the implementation of the eHealth intervention were documented on case report forms, alarm event forms, and a nursing user feedback questionnaire. These data were collated by the research and nursing personnel and submitted to the research coordinator. In this evaluation report, the clinical adoption framework was used as a guide to organize the identified issues and evaluate their impact. Results Using the clinical adoption framework, we identified issues within the framework dimensions of people, organization, and implementation at the meso level, as well as standards and funding issues at the macro level. Key issues included: nursing workflow changes with blank alarm forms (24/1030, 2.33%) and missing alarm forms (236/1030, 22.91%), patient withdrawal (110/1030, 10.68%), wireless network connectivity, false alarms (318/1030, 30.87%), monitor malfunction (36/1030, 3.49%), probe issues (16/1030, 1.55%), and wireless network standards. At the micro level, these issues affected the quality of the service in terms of support provided, the quality of the information yielded by the monitors, and the functionality, reliability, and performance of the monitoring system. As a result, these issues impacted access through the decreased ability of nurses to make complete use of the monitors, impacted care quality of the trial intervention through decreased effectiveness, and impacted productivity through interference in the coordination of care, thus decreasing clinical adoption of the monitoring system. Conclusions Patient monitoring with eHealth technology in surgical wards has the potential to improve patient outcomes. However, proper planning that includes engagement of front-line nurses, installation of appropriate wireless network infrastructure, and use of comfortable cableless devices is required to maximize the potential of eHealth monitoring. Trial Registration ClinicalTrials.gov NCT02907255; https://clinicaltrials.gov/ct2/show/NCT02907255

Our objective is to evaluate intravenous (IV) fluid prescription practice patterns in critically ill children in the first 72 hours of pediatric intensive care unit (PICU) admission and to evaluate the incidence and predictors of hyperchloremic metabolic acidemia (HCMA) and the association between HCMA and adverse outcomes. This retrospective cohort study was conducted in two tertiary-care Canadian PICUs. Children aged 0 to 18 years admitted to the PICU between January 2015 and January 2016 who received at least 50% of their calculated maintenance fluid requirements parenterally during the first 24 hours of admission were included. Children with known preexisting conditions associated with HCMA, such as renal tubular acidosis and gastrointestinal bicarbonate losses, were excluded. Of the 771 children screened, 543 met eligibility criteria and were included. The commonest prescribed maintenance fluid was 0.9% NaCl (72.9%) followed by lactated Ringer's solution (19.6%) and hypotonic solutions (4.6%). Balanced salt solutions (i.e., lactated Ringer's and Plasma-Lyte) were as commonly administered as unbalanced solutions (0.9% NaCl) for volume expansion (49.6 vs. 48.5%, respectively). Medications contributed to a significant proportion of total daily intake, in excess of bolus fluids. The incidence of hyperchloremia and HCMA was 94.9% (95% confidence interval [CI]: 93.2–96.9; 470/495) and 38.9% (95% CI: 34.6–43.2; 196/504), respectively. Predictors of HCMA were increasing combined bolus and maintenance 0.9% NaCl intake (odds ratio: 1.13; 95% CI: 1.04–1.23) and increasing severity of illness. HCMA was not associated with an increased risk of acute kidney injury, feeding intolerance, or PICU-acquired weakness. Isotonic fluids, specifically 0.9% NaCl, were the most commonly administered maintenance IV fluid in critically ill children. Sources of chloride load are not isolated to resuscitation fluids as previously suggested. Maintenance fluids and fluids administered with medications and IV flushes (fluid creep) are under-recognized significant sources of fluid and electrolyte intake in critically ill children. HCMA is common, and further prospective research is required to determine whether HCMA is indeed harmful in children. However, all significant sources of fluid should be accounted for in the design of future trials comparing balanced and unbalanced salt solutions.

Background Opioids remain the mainstay therapy for post-surgical pain. Although both morphine and hydromorphone are potent analgesics, it has been suggested that hydromorphone is clinically better. Our primary objective was to compare morphine with hydromorphone for achieving satisfactory analgesia with minimal emesis (SAME). Methods We performed a multicentre RCT in 402 patients having ambulatory surgery. A random computer-generated allocation, stratified by site, was developed by our pharmacy. Concealment was achieved by allocating patients to study groups by nurses using sequentially coded study medication syringes having equi-analgesic doses, made available in the postoperative recovery room. Patients, health providers, and research personnel were blinded. The operating-room protocol allowed for routine anaesthetic management, excluding the use of study medications. Study medications were administered by recovery nurses as per an algorithm. Analyses utilised the intention-to-treat principle, and regression analyses were used for outcomes as appropriate and using multiple imputation. Results Of 751 patients, 402 were randomised between morphine (n=199) and hydromorphone (n=203). Baseline and intraoperative variables were comparable across the groups. The odds of achieving SAME were similar between the groups (odds ratio: 1.01; 95% confidence interval: 0.57–1.80). There were no differences in the side-effects of severe itching, respiratory depression, or sedation. Patient satisfaction, discharge times, and post-discharge outcomes, including pain and nausea/vomiting over 24 h, were also comparable. Conclusions There was no difference between morphine and hydromorphone regarding analgesia and common side-effects. The appearance of dose-limiting side-effects is idiosyncratic; the clinical decision must be based on individual responses. Clinical trial registration NCT02223377.

Importance Community-acquired pneumonia (CAP) is a common occurrence in childhood; consequently, evidence-based recommendations for its treatment are required. Objective To determine whether 5 days of high-dose amoxicillin for CAP was associated with noninferior rates of clinical cure compared with 10 days of high-dose amoxicillin. Design, Setting, and Participants The SAFER (Short-Course Antimicrobial Therapy for Pediatric Respiratory Infections) study was a 2-center, parallel-group, noninferiority randomized clinical trial consisting of a single-center pilot study from December 1, 2012, to March 31, 2014, and the follow-up main study from August 1, 2016, to December 31, 2019 at the emergency departments of McMaster Children’s Hospital and the Children’s Hospital of Eastern Ontario. Research staff, participants, and outcome assessors were blinded to treatment allocation. Eligible children were aged 6 months to 10 years and had fever within 48 hours, respiratory symptoms, chest radiography findings consistent with pneumonia as per the emergency department physician, and a primary diagnosis of pneumonia. Children were excluded if they required hospitalization, had comorbidities that would predispose them to severe disease and/or pneumonia of unusual origin, or had previous β-lactam antibiotic therapy. Data were analyzed from March 1 to July 8, 2020. Interventions Five days of high-dose amoxicillin therapy followed by 5 days of placebo (intervention group) vs 5 days of high-dose amoxicillin followed by a different formulation of 5 days of high-dose amoxicillin (control group). Main Outcomes and Measures Clinical cure at 14 to 21 days. Results Among the 281 participants, the median age was 2.6 (interquartile range, 1.6-4.9) years (160 boys [57.7%] of 279 with sex listed). Clinical cure was observed in 101 of 114 children (88.6%) in the intervention group and in 99 of 109 (90.8%) in the control group in per-protocol analysis (risk difference, −0.016; 97.5% confidence limit, −0.087). Clinical cure at 14 to 21 days was observed in 108 of 126 (85.7%) in the intervention group and in 106 of 126 (84.1%) in the control group in the intention-to-treat analysis (risk difference, 0.023; 97.5% confidence limit, −0.061). Conclusions and Relevance Short-course antibiotic therapy appeared to be comparable to standard care for the treatment of previously healthy children with CAP not requiring hospitalization. Clinical practice guidelines should consider recommending 5 days of amoxicillin for pediatric pneumonia management in accordance with antimicrobial stewardship principles. Trial Registration ClinicalTrials.gov Identifier:NCT02380352

Individuals with human immunodeficiency virus (HIV) represent a population that is at a higher risk of developing chronic obstructive pulmonary disease (COPD). In this study, we sought to determine the effects of smoking on respiratory symptoms and diseases among HIV-positive patients and to determine if symptomatic patients are being appropriately screened for COPD. HIV-positive individuals completed a self-administered questionnaire. The effects of smoking on respiratory symptoms and diseases were reported as odds ratios (ORs). The COPD screening criteria were adapted from the Canadian Thoracic Society (CTS) guidelines. Two hundred and forty-seven participants were recruited. The median age was 49 years; 75% were male and 92% were on highly active antiretroviral therapy. Smokers represented 66% of the population. Smoking had a statistically significant effect on respiratory symptoms including wheeze (OR 4.8 [95% confidence interval (CI) 1.6-14.2]), phlegm production (OR 4.9 [95% CI: 2.2-10.5]), cough (OR 7.0 [95% CI: 3.0-16.2]), and dyspnea (OR 7.2 [95% CI: 1.7-31.2]). Smoking had a higher odds of respiratory diseases including COPD (OR 4.9 [95% CI: 1.1-21.9]) and bronchitis (OR 3.8 [95% CI: 1.9-7.7]). Among HIV-positive smokers, 40% met the CTS screening criteria, while only 12% self-reported a diagnosis of COPD. The burden of smoking in the HIV population is significant. HIV-positive smokers are more likely to report both respiratory symptoms and diseases than HIV-positive non-smokers. A discrepancy exists between patients who met the CTS screening criteria and those who were diagnosed with COPD, raising the concern for under-recognition and under-diagnosis of COPD in this population.

Introduction Moderate to severe postoperative pain and associated opioid use may interfere with patients' well-being and course of recovery. Regional anesthetic techniques provide an opportunity for opioid sparing and improved patient outcomes. A new regional technique called the erector spinae plane (ESP) block has the potential to provide effective analgesia after shoulder arthroscopy with minimal risks and decreased opioid consumption. Our primary objective is to determine whether, in patients who undergo arthroscopic shoulder surgery, a preoperative ESP block reduces pain scores as compared to periarticular infiltration at the end of surgery. Additionally, we will also examine other factors such as opioid consumption, sensory block, adverse events, patient satisfaction, and persistent pain. Methods This is a 2-arm, single-center, parallel-design, double-blind randomized controlled trial of 60 patients undergoing arthroscopic shoulder surgery. Eligible patients will be recruited in the preoperative clinic. Using a computer-generated randomization, with a 1:1 allocation ratio, patients will be randomized to either the ESP or periarticular infiltration group. Patients will be followed in hospital in the postanesthesia care unit, at 24 hours, and at 1 month. The study with be analyzed as intention-to-treat. Discussion This study will inform an evidence-based choice in recommending ESP block for shoulder arthroscopy, as well as providing safety data. The merits of the study include its double dummy blinding to minimize observer bias, and its assessment of patient important outcomes, including pain scores, opioid consumption, and patient satisfaction. This study will also help provide an estimate of the incidence of side effects and complications of the ESP block. Trial registration number NCT03691922; Recruited Date of registration: October 2, 2018.

Objective: To evaluate short-term respiratory outcomes, mortality and bronchopulmonary dysplasia (BPD) in preterm infants born to mothers with and without pregnancy induced hypertension (PI...

In general, clinical research network capacity building refers to programs aimed at enhancing networks of researchers to conduct clinical research. Although in the literature there is a large body of research on how to develop and build capacity in clinical research networks, the conceptualizations and implementations remain controversial and challenging. Moreover, the experiences learnt from the past accomplishments and failures can assist in the future capacity building efforts to be more practical, effective and efficient. In this paper, we aim to provide an overview of capacity building in clinical research network by (1) identifying the key barriers to clinical research network capacity building, (2) providing insights into how to overcome those obstacles, and (3) sharing our experiences in collaborating with national and international partners to build capacity in clinical research networks. In conclusion, we have provided some insight into how to address the key factors of clinical research network capacity building and shared some empirical experiences. A successful capacity building practice requires a joint endeavor to procure sufficient resources and support from the relevant stakeholders, to ensure its efficiency, cost-effectiveness, and sustainability.

Low-risk syncope accounts for a large proportion of hospital admissions; however, inpatient investigations are often not necessary and are rarely diagnostic. Reducing the number of low-risk syncope admissions can likely lower health care resource consumption and overall expenditure. Application of syncope guidelines by physicians in the emergency department provides a standardized approach that may potentially reduce admissions and lead to health care resource utilization savings.A retrospective chart review of 1229 syncope presentations was conducted at 2 major academic centres spanning 1 year. Three major society guidelines and position statements were applied to determine the effect on admission rates.A total of 1031 true syncope charts were included in the analysis; 407 (39%) were admitted and 624 (61%) were discharged by the treating physician (MD). There was a significant difference in the mean [standard deviation] age (75 [14] vs 55 [22]) and baseline cardiovascular disease, including congestive heart failure 51/407 (13%) vs 28/624 (5%), coronary artery disease 125/407 (31%) vs 91/624 (15%), and structural heart disease 36/407 (9%) vs 26/624 (4%), between admitted and not admitted patients, respectively (P0.01). All guidelines warranted more low-risk admissions when compared with 19% by the MD: Canadian Cardiovascular Society 34% (P0.01), American College of Emergency Physicians 22% (P = 0.03), and European Society of Cardiology 26% (P0.01).In conclusion, application of the current syncope guidelines to an emergency department population is unlikely to reduce low-risk hospital admissions.

Background The study purpose was to identify tumor and surgeon predictors of local recurrence (LR), regional recurrence (RR), and distant metastasis (DM) after breast cancer (BC) surgery in a population-based cohort. Methods Consecutive BC surgical cases from 12 hospitals in South Central Ontario between May 2006 and October 2006 were included. Data collected on chart review included patient and tumor factors, surgery type, adjuvant treatment, surgeon specialty, surgeon case volume, and practice type. Univariate and multivariable survival analyses were performed. Results Median follow-up was 5.5 years for 402 patients (97% of sample). LR, RR, and DM occurred in 18 (4.5%), 10 (2.5%), and 47 (12%) patients, respectively. Significant predictors of BC recurrence (LR or RR or DM) were tumor size and grade, nodal status, and lymphovascular invasion on multivariable analysis. Conclusion Tumor factors such as size, grade, lymphovascular invasion, and nodal status predicted BC recurrence, while practice type, surgeon specialty, and case volume did not.

Made available in DSpace on 2018-11-26T15:45:27Z (GMT). No. of bitstreams: 0 Previous issue date: 2017-08-01 Objective: To conduct (1) a systematic survey of the reporting quality of simulation studies dealing with how to handle missing participant data (MPD) in randomized control trials and (2) summarize the findings of these studies. Study Design and Setting: We included simulation studies comparing statistical methods dealing with continuous MPD in randomized controlled trials addressing bias, precision, coverage, accuracy, power, type-I error, and overall ranking. For the reporting of simulation studies, we adapted previously developed criteria for reporting quality and applied them to eligible studies. Results: Of 16,446 identified citations, the 60 eligible generally had important limitations in reporting, particularly in reporting simulation procedures. Of the 60 studies, 47 addressed ignorable and 32 addressed nonignorable data. For ignorable missing data, mixed model was most frequently the best on overall ranking (9 times best, 34.6% of times tested) and bias (10, 55.6%). Multiple imputation was also performed well. For nonignorable data, mixed model was most frequently the best on overall ranking (7, 46.7%) and bias (8, 57.1%). Mixed model performance varied on other criteria. Last observation carried forward (LOCF) was very seldom the best performing, and for nonignorable MPD frequently the worst. Conclusion: Simulation studies addressing methods to deal with MPD suffered from serious limitations. The mixed model approach was superior to other methods in terms of overall performance and bias. LOCF performed worst. (C) 2017 Elsevier Inc. All rights reserved. McMaster Univ, Dept Hlth Res Methods Evidence & Impact, Hamilton, ON, Canada China Acad Chinese Med Sci, Guanganmen Hosp, Beijing, Peoples R China Kerman Univ Med Sci, Reg Knowledge Hub, Kerman, Iran Kerman Univ Med Sci, WHO, Collaborating Ctr HIV Surveillance, Inst Futures Studies Hlth, Kerman, Iran Univ Antioquia, Dept Pediat, Medellin, Colombia Univ Toronto, Dept Diagnost Radiol, Toronto, ON, Canada McMaster Univ, Dept Math & Stat, Hamilton, ON, Canada Hosp Angeles Carmen, Dept Crit Care, Guadalajara, Jalisco, Mexico Singapore Gen Hosp, Nursing Div, Singapore, Singapore Univ Sorocaba, Dept Pharmaceut Sci, Sao Paulo, Brazil Univ Estadual Paulista, Dept Pharmaceut Sci, Sao Paulo, Brazil Beijing Univ Chinese Med, Ctr Evidence Based Chinese Med, Chaoyang Qu, Peoples R China Michael G DeGroote Natl Pain Ctr, Dept Anesthesiol, Hamilton, ON, Canada Amer Univ Beirut, Dept Internal Med, Beirut, Lebanon McMaster Univ, Dept Pathol & Mol Med, Hamilton, ON, Canada Amer Univ Beirut, Clin Epidemiol Unit, Beirut, Lebanon Amer Univ Beirut, Ctr Systemat Reviews Hlth Policy & Syst Res SPARK, Beirut, Lebanon Dept Med, Hamilton, ON, Canada Dept Hlth Res Methods Evidence & Impact, Hamilton, ON, Canada Univ Estadual Paulista, Dept Pharmaceut Sci, Sao Paulo, Brazil

Importance Despite increasing emphasis on conservative management of patent ductus arteriosus (PDA) in preterm infants, different pharmacotherapeutic interventions are used to treat those developing a hemodynamically significant PDA. Objectives To estimate the relative likelihood of hemodynamically significant PDA closure with common pharmacotherapeutic interventions and to compare adverse event rates. Data Sources and Study Selection The databases of MEDLINE, Embase, and the Cochrane Central Register of Controlled Trials were searched from inception until August 15, 2015, and updated on December 31, 2017, along with conference proceedings up to December 2017. Randomized clinical trials that enrolled preterm infants with a gestational age younger than 37 weeks treated with intravenous or oral indomethacin, ibuprofen, or acetaminophen vs each other, placebo, or no treatment for a clinically or echocardiographically diagnosed hemodynamically significant PDA. Data Extraction and Synthesis Data were independently extracted in pairs by 6 reviewers and synthesized with Bayesian random-effects network meta-analyses. Main Outcomes and Measures Primary outcome: hemodynamically significant PDA closure; secondary: included surgical closure, mortality, necrotizing enterocolitis, and intraventricular hemorrhage. Results In 68 randomized clinical trials of 4802 infants, 14 different variations of indomethacin, ibuprofen, or acetaminophen were used as treatment modalities. The overall PDA closure rate was 67.4% (2867 of 4256 infants). A high dose of oral ibuprofen was associated with a significantly higher odds of PDA closure vs a standard dose of intravenous ibuprofen (odds ratio [OR], 3.59; 95% credible interval [CrI], 1.64-8.17; absolute risk difference, 199 [95% CrI, 95-258] more per 1000 infants) and a standard dose of intravenous indomethacin (OR, 2.35 [95% CrI, 1.08-5.31]; absolute risk difference, 124 [95% CrI, 14-188] more per 1000 infants). Based on the ranking statistics, a high dose of oral ibuprofen ranked as the best pharmacotherapeutic option for PDA closure (mean surface under the cumulative ranking [SUCRA] curve, 0.89 [SD, 0.12]) and to prevent surgical PDA ligation (mean SUCRA, 0.98 [SD, 0.08]). There was no significant difference in the odds of mortality, necrotizing enterocolitis, or intraventricular hemorrhage with use of placebo or no treatment compared with any of the other treatment modalities. Conclusions and Relevance A high dose of oral ibuprofen was associated with a higher likelihood of hemodynamically significant PDA closure vs standard doses of intravenous ibuprofen or intravenous indomethacin; placebo or no treatment did not significantly change the likelihood of mortality, necrotizing enterocolitis, or intraventricular hemorrhage. Trial Registration PROSPERO Identifier: CRD42015015797

OBJECTIVE Changing clinician practice in pediatric critical care is often difficult. Tailored knowledge translation interventions may be more effective than other types of interventions. To inform the design of tailored interventions, the primary objective of this survey was to describe the importance of specific factors that influence physicians and pharmacists when they make decisions about medications in critically ill children. DESIGN In this postal survey, respondents used 7-point scales to rate the importance of specific factors that influence their decisions in the following scenarios: corticosteroids for shock, intensive insulin therapy, stress ulcer prophylaxis, surfactant for acute respiratory distress syndrome, and sedation interruption. We used generalized estimating equations to examine the association between the importance of specific factors influencing decision making and the scenario and respondents' practice, views, and demographics. SETTING Canadian PICUs. PARTICIPANTS One hundred and seventeen physicians and pharmacists practicing in 18 PICUs. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS The response rate was 61%. The three factors reported to most strongly influence clinician decision making overall were: severity of illness (mean [SD] 5.8 [1.8]), physiologic rationale (5.2 [1.3]), and adverse effects (5.1 [1.9]). Factors least likely to influence decision making were drug costs (2.0 [1.5]), unit policies (2.9 [1.9]), and non-critical care randomized controlled trials (3.1 [1.9]). The relative importance of 8 of the 10 factors varied significantly among the five scenarios: only randomized controlled trials in critically ill children and other clinical research did not vary. Clinician characteristics associated with the greatest difference in importance ratings were: frequent use of the intervention in that scenario (seven factors), profession (five factors), and respondents' assessment of the quality of evidence (five factors). CONCLUSIONS The relative importance of many factors that clinicians consider when making decisions about medications varies by demographics, and depends on the clinical problem. This variability should be considered in quality improvement and knowledge translation interventions in this setting.

Purpose. To compare the efficacy of individualized herbal decoction with controlled decoction for individual patients with stable bronchiectasis.Methods. We conducted N-of-1 RCTs (single-patient, double-blind, randomized, multiple crossover design) in 3 patients with stable bronchiectasis. The primary outcome was patient self-rated symptom scores on visual analogue scales. Secondary outcome was 24-hour sputum volume. A clinical efficacy criterion which combined symptoms score and medication preference was also formulated.Results. All three patients showed various degrees of improvement on their symptoms and one patient’s (Case 3) 24 h sputum volume decreased from 70 mL to 30 mL. However, no significant differences were found between individualized herbal decoction and control decoction on symptoms score, or on 24-hour sputum volume. One patient (Case 2) had clear preference for the individualized herbal decoction over the standard one with the confirmation after unblinding. We therefore considered this case as clinically important.Discussion. N-of-1 trials comply with individualized philosophy of TCM clinical practice and had good compliance. It is necessary to set up clinical efficacy criteria and to consider the interference of acute exacerbation.

We sought to determine if the publication of the Consolidated Standards of Reporting Trials (CONSORT)(1) extension for abstracts in 2008 had led to an improvement in reporting abstracts of randomized controlled trials (RCTs).(2) METHODS: We searched PubMed for RCTs published in 2007 and 2012 in top-tier general medicine journals. A random selection of 100 trial abstracts was obtained for each year. Data were extracted in duplicate on the adherence to the CONSORT extension for abstracts. The primary outcome was the mean number of items reported and the secondary outcome was the odds of reporting each item. We also estimated incidence rate ratios (IRRs).(3) RESULTS: Significantly more checklist items were reported in 2012 than in 2007: adjusted mean difference was 2.91 (95% confidence interval [CI](4) 2.35, 3.41; p0.001). In 2012 there were significant improvements in reporting the study as randomized in the title, describing the trial design, the participants, and objectives and blinding. In the Results section, trial status and numbers analyzed were also reported better. The IRRs were significantly higher for 2012 (IRR 1.32; 95% CI 1.25, 1.39; p0.001) and in multisite studies compared to single site studies (IRR 1.08; 95% CI 1.03, 1.15; p=0.006).There was a significant improvement in the reporting of abstracts of RCTs in 2012 compared to 2007. However, there is still room for improvement as some items remain under-reported.

Objectives Discrete choice experiments (DCEs) are routinely used to elicit patient preferences to improve health outcomes and healthcare services. While many fractional factorial designs can be created, some are more statistically optimal than others. The objective of this simulation study was to investigate how varying the number of (1) attributes, (2) levels within attributes, (3) alternatives and (4) choice tasks per survey will improve or compromise the statistical efficiency of an experimental design. Design and methods A total of 3204 DCE designs were created to assess how relative design efficiency (d-efficiency) is influenced by varying the number of choice tasks (2–20), alternatives (2–5), attributes (2–20) and attribute levels (2–5) of a design. Choice tasks were created by randomly allocating attribute and attribute level combinations into alternatives. Outcome Relative d-efficiency was used to measure the optimality of each DCE design. Results DCE design complexity influenced statistical efficiency. Across all designs, relative d-efficiency decreased as the number of attributes and attribute levels increased. It increased for designs with more alternatives. Lastly, relative d-efficiency converges as the number of choice tasks increases, where convergence may not be at 100% statistical optimality. Conclusions Achieving 100% d-efficiency is heavily dependent on the number of attributes, attribute levels, choice tasks and alternatives. Further exploration of overlaps and block sizes are needed. This study9s results are widely applicable for researchers interested in creating optimal DCE designs to elicit individual preferences on health services, programmes, policies and products.