Increased Household Secondary Attacks Rates With Variant of Concern Severe Acute Respiratory Syndrome Coronavirus 2 Index Cases.

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.

End-of-Life Skills and Professionalism for Critical Care Residents in Training: The ESPRIT Survey.

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.

Intraoperative neurophysiologic monitoring in idiopathic scoliosis surgery: a retrospective observational study of new neurologic deficits.

PURPOSE: 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. METHODS: 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. RESULTS: 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. CONCLUSION: 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.

Hydromorphone versus morphine: a historical cohort study to evaluate the quality of postoperative analgesia.

PURPOSE: 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). METHODS: 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. RESULTS: 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. CONCLUSION: 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.

Factors associated with treatment failure of high-flow nasal cannula among children with bronchiolitis: a single-centre retrospective study.

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<0.001), such that deterioration is less likely once patients have remained stable on HFNC for a prolonged time. 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.

Stress Ulcer Prophylaxis in Critically Ill Children: A Multicenter Observational Study.

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.

Interventional pain management for chronic pain: a survey of physicians in Canada.

PURPOSE: 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. METHODS: We administered a 32-item survey via seven Canadian physician member organizations, whose members were engaged in the management of chronic pain. RESULTS: 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. CONCLUSIONS: 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.

What Antibullying Program Designs Motivate Student Intervention in Grades 5 to 8?

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 (N = 2,033) completed a discrete choice experiment examining the influence of 11 AB program attributes on the decision to intervene. Multilevel analysis revealed 6 latent classes. The Intensive Programming class (28.7%) thought students would intervene in schools with daily AB activities, 8 playground supervisors, mandatory reporting, and suspensions for perpetrators. A Minimal Programming class (10.3%), in contrast, thought monthly AB activities, 4 playground supervisors, discretionary reporting, and consequences limited to talking with teachers would motivate intervention. Membership in this class was linked to Grade 8, higher dispositional reactance, more reactance behavior, and more involvement as perpetrators. The remaining 4 classes were influenced by different combinations of these attributes. Students were more likely to intervene when isolated peers were included, other students intervened, and teachers responded quickly. Latent class analysis points to trade-offs in program design. Intensive programs that encourage intervention by students with little involvement as perpetrators may discourage intervention by those with greater involvement as perpetrators, high dispositional reactance, or more reactant behavior.

Association of Placebo, Indomethacin, Ibuprofen, and Acetaminophen With Closure of Hemodynamically Significant Patent Ductus Arteriosus in Preterm Infants: A Systematic Review and Meta-analysis.

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.

Chronic obstructive pulmonary disease and HIV: are we appropriately screening?

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.

Making decisions about medications in critically ill children: a survey of Canadian pediatric critical care clinicians.

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.

Exploring comparative assessment of adiposity measures during pregnancy and postpartum.

BACKGROUND & AIMS: Excessive adiposity in pregnancy is associated with an altered cardiometabolic profile and adverse maternal and offspring outcomes. Pre-pregnancy body mass index (pBMI) is a proxy measure for adiposity that is most often used in clinical settings; however, it may not identify at-risk pregnancies caused by adiposity-related cardiometabolic dysfunction. The challenge is that validated direct adiposity measures are limited due to the dynamic nature of pregnancy. This exploratory analysis aimed to, 1) evaluate longitudinal changes in % body fat (BF) and the agreement between skinfold thickness (SFT) and bioelectrical impedance analysis (BIA) across pregnancy and in postpartum; 2) compare the discrimination power of SFT, BIA, and pBMI regarding adiposity status; and 3) assess agreement between SFT and BIA with dual-energy X-ray absorptiometry (DXA) in the postpartum. METHODS: Participants enrolled in the Be Healthy in Pregnancy (BHIP) RCT (NCT01693510) had demographic data and pBMI collected at enrollment and adiposity measured at 12-17, 26-28, and 36-38 weeks gestation by BIA (%BF) and SFT (sum and %BF), and also by DXA at 6 months postpartum. Agreement between methods was assessed by Bland Altman plots and McNemar's test and C-statistic for discriminative power. RESULTS: In 181 women with mean pBMI of 25.1 kg/m2 (min: 17.4 kg/m2, max: 39.6 kg/m2) and age 31.6 (SD: 4.0 yr), maternal adiposity increased significantly (p < 0.001) across pregnancy when measured by the sum of SFT or %BF by BIA, but not %BF by SFT. In early pregnancy, BF by BIA and SFT showed good agreement, with BIA values 1.8% greater than SFT, but low agreement in late pregnancy, with BIA values 7.1% greater than SFT. However, in the postpartum, agreement was similar to early pregnancy, and both BIA and SFT demonstrated good agreement with DXA. By pBMI, 45.5% of participants were categorized as overweight/obese, compared to 66.5% by BIA (p < 0.0001) and 54.5% by SFT (p < 0.0001). CONCLUSIONS: In comparison to SFT and BIA, the results suggest that pBMI is less sensitive in identifying participants with excessive adiposity, limiting its use as a screening tool for adiposity-related adverse outcomes in pregnancy. It would be preferable to use a direct measure of adiposity to screen for at-risk pregnancies. Both %BF by BIA and sum of SFT can quantify the change in adiposity across pregnancy and in the postpartum and thus could be adopted as clinical practice tools. Future research efforts should further refine and validate adiposity techniques for use, particularly in mid and late pregnancy. CLINICAL TRIAL: The BHIP clinical trial (NCT01693510). REGISTRATION SITE: https://clinicaltrials.gov/ct2/show/NCT01693510.

Be Healthy in Pregnancy (BHIP): A Randomized Controlled Trial of Nutrition and Exercise Intervention from Early Pregnancy to Achieve Recommended Gestational Weight Gain.

A randomized two-arm prospective superiority trial tested the efficacy of a novel structured and monitored nutrition (bi-weekly counselling for individualized energy and high dairy protein diet) and exercise program (walking goal of 10,000 steps/day) (intervention) compared to usual care (control) in pregnant women to achieve gestational weight gain (GWG) within current recommendations. Women recruited in communities in southern Ontario, Canada were randomized at 12-17 weeks gestation with stratification by site and pre-pregnancy BMI to intervention (n = 119) or control (n = 122). The primary outcome was the proportion of women who achieved GWG within the Institute of Medicine recommendations. Although the intervention compared to control group was more likely to achieve GWG within recommendations (OR = 1.51; 95% CI (0.81, 2.80)) and total GWG was lower by 1.45 kg (95% CI: (-11.9, 8.88)) neither reached statistical significance. The intervention group achieved significantly higher protein intake at 26-28 week (mean difference (MD); 15.0 g/day; 95% CI (8.1, 21.9)) and 36-38 week gestation (MD = 15.2 g/day; 95% CI (9.4, 21.1)) and higher healthy diet scores (22.5 ± 6.9 vs. 18.7 ± 8.5, p < 0.005) but step counts were similar averaging 6335 steps/day. Pregnancy and infant birth outcomes were similar between groups. While the structured and monitored nutrition with counselling improved diet quality and protein intake and may have benefited GWG, the exercise goal of 10,000 steps/day was unachievable. The results can inform future recommendations for diet and physical activity in pregnancy.

Postoperative pain after intrathecal analgesia in laparoscopic liver resection: a retrospective chart review.

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.

Continuous erector spinae plane block versus intercostal nerve block in patients undergoing video-assisted thoracoscopic surgery: a pilot randomized controlled trial.

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.

Short-Course Antimicrobial Therapy for Pediatric Community-Acquired Pneumonia: The SAFER Randomized Clinical Trial.

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 ß-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.

Neonatal respiratory outcomes in pregnancy induced hypertension: introducing a novel index.

Objective: To evaluate short-term respiratory outcomes, mortality and bronchopulmonary dysplasia (BPD) in preterm infants born to mothers with and without pregnancy induced hypertension (PIH).Methods: Exposed infants <33 weeks' gestation were matched to controls in a 1:2 ratio, based on gestation, sex and antenatal steroid exposure in this retrospective cohort study. Primary outcomes were a novel cumulative respiratory index (cRI) (product of mean airway pressure-hours and FiO2-hours while on invasive ventilation during first 72 hours), mortality and BPD.Results: Seventy-nine exposed infants were matched with 158 controls. cRI was higher in exposed infants (median 1854; IQR 186-13,901) versus controls (median 1359; IQR 210-11,302) but not statistically significant (p = .63). On conditional regression analysis, PIH did not predict cRI (adjusted ß = 0.96; 95% CI = 0.79-1.17; p = .712). No association between PIH and mortality (unadjusted odds ratio [OR] = 3.14; 95% CI = 0.76-13.0; p=.11) was identified. PIH was significantly associated with BPD on univariate analysis (OR = 2.29; 95% CI = 1.02-5.17; p=.046), but not after adjustment (aOR = 1.26; 95% CI = 0.38-4.19; p=.7).Conclusions: PIH was not associated with cRI, mortality or BPD in this study. Further validation of cRI and exploration of its relationship with PIH as well as neonatal outcomes is warranted.

Randomized control trial of ultrasound-guided erector spinae block versus shoulder periarticular anesthetic infiltration for pain control after arthroscopic shoulder surgery: Study protocol clinical trial (SPIRIT compliant).

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.

What Influences Educators' Design Preferences for Bullying Prevention Programs? Multi-level Latent Class Analysis of a Discrete Choice Experiment.

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.