It's About Time: Rapid Implementation of a Hub-and-Spoke Care Delivery Model for Tertiary-Integrated Complex Care Services in a Northern Ontario Community.

Children with medical complexity (CMC) in rural and northern communities have more difficulty accessing subspecialty health providers than those in urban centres. This article describes an alignment cascade in which leaders engaged peers and staff to rapidly roll out the implementation of a sustainably designed complex care model, integrated in the Champlain Complex Care Program and delivered in Timmins, Ontario. The Provincial Council for Maternal and Child Health's Complex Care for Kids Ontario (CCKO) strategy supports the implementation and expansion of a hub-and-spoke model of interprofessional complex care for CMC and their families. A nurse practitioner is the primary point of contact for the family and oversees coordination and integration of care; regional CCKO programs are committed to building capacity to provide safe, high-quality care for CMC in communities closer to their homes.

Association between fraction of exhaled nitrous oxide, bronchodilator response and inhaled corticosteroid type.

BACKGROUND: Fraction of exhaled nitrous oxide (FeNO) is a known marker of airway inflammation and a topic of recent investigation for asthma control in children. OBJECTIVE: To investigate the relationship among FeNO and bronchodilator response measured by spirometry and types of inhaled corticosteroids (ICS). METHODS: A one-year review of children tested with spirometry and FeNO in a regional pediatric asthma centre was conducted. RESULTS: A total of 183 children were included (mean [± SD] age 12.8 ± 2.8 years). Fluticasone was used most commonly (n=66 [36.1%]), followed by ciclesonide (n=50 [27.3%]). Most children (n=73 [39.9%]) had moderate persistent asthma. Increased FeNO was associated with percent change in forced expiratory volume in 1 s (FEV1) after bronchodilator adjusted for allergic rhinitis, parental smoking and ICS type (B=0.08 [95% CI 0.04 to 0.12]; P<0.001). Similarly, FeNO was associated with percent change in forced expiratory flow at 25% to 75% of the pulmonary volume (FEF25-75) after bronchodilator adjusted for parental smoking and ICS type (B=0.13 [95% CI 0.01 to 0.24]; P=0.03). FeNO accounted for only 16% and 9% of the variability in FEV1 and FEF25-75, respectively. Mean-adjusted FeNO was lowest in fluticasone users compared with no ICS (mean difference 18.6 parts per billion [ppb] [95% CI 1.0 to 36.2]) and there was no difference in adjusted FeNO level between ciclesonide and no ICS (5.9 ppb [95% CI -9.0 to 20.8]). CONCLUSION: FeNO levels correlated with bronchodilator response in a regional pediatric asthma centre. However, FeNO accounted for only 16% and 9% of the variability in FEV1 and FEF25-75, respectively. Mean adjusted FeNO varied according to ICS type, suggesting a difference in relative efficacy between ICS beyond their dose equivalents.

Prevalence of hypothalamic-pituitary-adrenal axis suppression in children treated for asthma with inhaled corticosteroid.

OBJECTIVE: To determine the prevalence of hypothalamic-pituitary-adrenal (HPA) axis suppression in asthmatic children on inhaled corticosteroids (ICS). METHODS: Clinical and demographic variables were recorded on preconstructed, standardized forms. HPA axis suppression was measured by morning serum cortisol levels and confirmed by low-dose adrenocorticotropic hormone stimulation testing. RESULTS: In total, 214 children participated. Twenty children (9.3%, 95% CI 5.3% to 13.4%) had HPA axis suppression. Odds of HPA axis suppression increased with ICS dose (OR 1.005, 95% CI 1.003 to 1.009, P<0.001). All children with HPA axis suppression were on a medium or lower dose of ICS for their age (200 µg/day to 500 µg/day). HPA axis suppression was not predicted by drug type, dose duration, concomitant use of long-acting beta-agonist or nasal steroid, or clinical features. CONCLUSION: Laboratory evidence of HPA axis suppression exists in children taking ICS for asthma. Children should be regularly screened for the presence of HPA axis suppression when treated with high-dose ICS (>500 µg/day). Consideration should be given to screening children on medium-dose ICS.

OBJECTIF: Déterminer la prévalence de suppression de l'axe hypothalamo-hypophyso-surrénalien (HHA) chez les enfants asthmatiques traités au moyen de corticoïdes par aérosol (CPA). MÉTHODOLOGIE: Les chercheurs ont obtenu des variables cliniques et démographiques à l'aide de formulaires standardisés préétablis. Ils ont mesuré la suppression de l'axe HHA au moyen de taux de cortisol sérique le matin et l'ont confirmée grâce à un test de stimulation à l'hormone adrénocorticotrope (ACTH) à faible dose. RÉSULTATS: Sur les 214 enfants qui ont participé à l'étude, 20 (9,3 %, 95 % IC 5,3 % à 13,4 %) présentaient une suppression de l'axe HHA. Le risque d'une telle suppression augmentait proportionnellement à la dose de CPA (RRR 1,005, 95 % IC 1,003 à 1,009, P<0,001). Tous les enfants présentant une suppression de l'axe HHA prenaient une dose moyenne à faible de CPA compte tenu de leur âge (200 µg/jour à 500 µg/jour). La suppression de l'axe HHA ne pouvait être prédite selon les caractéristiques cliniques, le type de médicament, la durée de la dose ou l'utilisation concomitante de bêta-agonistes à longue durée d'action ou de stéroïdes par voie nasale. CONCLUSION: Il existe des preuves de laboratoire de suppression de l'axe HHA chez les enfants qui prenaient des CPA pour traiter leur asthme. Il faudrait procéder au dépistage régulier de la suppression de l'axe HHA chez des enfants traités au moyen de fortes doses de CPA (plus de 500 µg/jour). Il faut également envisager de dépister les enfants traités au moyen d'une dose moyenne de CPA.

Prospective study of a noninvasive treatment for two common congenital toe abnormalities (curly/varus/underlapping toes and overlapping toes).

OBJECTIVE: To assess, in the newborn, the efficacy of a standard taping treatment used in children for two selected congenital toe abnormalities (curly/varus/underlapping toes and overlapping toes), and compare the outcome with the available world literature. METHODS: All children referred by their family physician between January 2004 and January 2006 were included. The newborns were reviewed by one author (WGS) within 10 days of birth, assessed for severity, and the toes were taped in a standard manner if the abnormalities met the study criteria. After one and two months, the same author reviewed the children, and retaped the toes. The children's toes were photographed before the taping and then after three months when the tape was removed permanently. After six months, the children, with their pictures, were sent to a second author (JTS), and were scored for the grade of severity and improvement using standard criteria. RESULTS: The world literature and standard textbooks indicate a 25% spontaneous improvement of these abnormalities. The recommendation is for surgical correction at a later date because intervention with taping has not shown success after the newborn period. No prior studies have been undertaken in the newborn. In the present study of 84 toes, the abnormality occurred in 2.8% of newborns, and 94% of the toes were improved or cured with no complications related to the technique. CONCLUSION: A simple, office-friendly technique of taping underlapping and overlapping toes in the newborn proved successful in 94% of the toes.

Approach to evaluation of sexual assault in children. Experience of a secondary-level regional pediatric sexual assault clinic.

OBJECTIVE: To determine whether a 3-year-old girl, brought to an after-hours clinic because her mother was concerned, had been assaulted by her father during a weekend visit. SOURCES OF INFORMATION MEDLINE: was searched using the key words child, sexual assault/abuse, and expectations. Recent textbooks on childhood sexual assault and abuse were consulted. The secondary-level regional pediatric sexual assault clinic's experience over 1 year was reviewed. Articles in the literature generally provide level II evidence. MAIN MESSAGE: The literature review and the clinic's experience both indicated that specialty centres for child sexual assault and abuse rarely produce positive physical findings that conclusively confirm or rule out sexual assault, especially when children are asymptomatic and not in an acute state. Primary care practitioners can use a brief history and physical examination to decide on the next level of care and determine the urgency of referral. Urgent assessment of children thought to have been abused or assaulted is required when children disclose assault (especially with genital-genital contact or ejaculation); when children have acute pain, bleeding, or discharge; when results of a physician's examination are abnormal; or when parents are extremely distressed. CONCLUSION: Family physicians have a pivotal role in evaluation of childhood sexual assault or abuse. Knowledge of the outcomes of evaluation is crucial to understanding when and how to refer.

Young people admitted on a Form 1 to a general hospital: A worrisome trend.

OBJECTIVE: To assess and analyze the significance of the increase in the number of paediatric psychiatric admissions under a Form 1 (involuntary admission) to the regional paediatric unit of a general hospital. METHODS: The authors retrospectively reviewed the charts of all child psychiatric admissions to the paediatric ward over the years 1998 to 2003. The specific data obtained was that of discharge diagnosis, age and sex of patient, application of Form 1 and transfer to a psychiatric facility. RESULTS: BROAD DIAGNOSTIC CATEGORIES INCLUDED: mood disorder with and without suicidal behaviour, suicidal behaviour, psychosis, mood disorder with psychosis, anxiety disorder, eating disorder, behaviour disorder, personality disturbance, substance abuse, situational crisis and psychogenic disorder. Yearly admissions to the unit ranged from 25 per year to 45 per year over the five years studied. In the last three years, the rate of Form 1 application increased from one in 1999 to 2000 to 11 in 2002 to 2003 (a 10 fold increase). DISCUSSION: Possible reasons for this dramatic increase were identified and may be relevant to other nonpsychiatric centres dealing with children.

Nonsurgical treatment of protruding ears: A case report and review of literature.

The nonsurgical correction of congenital ear deformities has been reported in the world literature. To date, there has been little interest in this procedure in pediatric centres and no reports in the Canadian literature. Two case reports are presented with a review of the literature. A description of this simple, user friendly office procedure is presented.

La correction non chirurgicale des malformations congénitales des oreilles est présentée dans la documentation médicale mondiale. Jusqu'à présent, on s'est peu intéressé à ces interventions dans les centres pédiatriques, et on ne trouve aucun compte rendu à ce sujet dans la documentation canadienne. Deux rapports de cas sont présentés, de même qu'une analyse bibliographique. Une description de cette intervention simple et conviviale effectuée en cabinet est exposée.

Community-based exercise assessment in children with high risk for type 2 diabetes.

OBJECTIVE: To assess the risk factors for a group of children at high risk for type 2 diabetes using a proven medical model and incorporating a community-friendly standardized fitness assessment tool. DESIGN: All children in school (kindergarten to grade eight) in an isolated First Nation community were enrolled to be screened for diabetes, risk factors, and fitness level. SETTING: Beausoleil First Nation community is an Ojibway community situated on Christian Island in Georgian Bay, Ontario, Canada. PARTICIPANTS: All children attending Christian Island Elementary School, a total of 101 students from kindergarten to grade eight. INTERVENTIONS: Capillary blood glucose fasting and 2 hours after 75-g simple carbohydrate meal, height and weight (calculated BMI), blood pressure, aerobic capacity, abdominal strength and endurance, upper body strength, trunk extensor strength and flexibility, and upper body flexibility. OUTCOME MEASUREMENTS: Applicability of tests to assess disease, risk factors, and fitness level. RESULTS: Eight children were found to have abnormal capillary blood glucose and required further laboratory investigations. Significant risk factors for type 2 diabetes were identified. The screening exercise assessment identified specific areas below that considered a healthy fitness zone. CONCLUSIONS: The screening assessment identified medical areas of concern in capillary blood glucose, blood pressure, and body mass index. The fitness testing identified areas of concern in aerobic capacity, upper body strength, abdominal strength and endurance, and flexibility. The fitness testing was First Nation community-friendly.