Celiac Disease and Inflammatory Bowel Disease Are Associated With Increased Risk of Eating Disorders: An Ontario Health Administrative Database Study.

INTRODUCTION: Previous national registry studies have reported an increased risk of eating disorders in immune-mediated conditions (inflammatory bowel disease and celiac disease). Our objective was to examine the association between immune-mediated gastrointestinal (GI) diseases and incident eating disorders in Ontario. METHODS: This was a retrospective matched cohort study of individuals <50 years of age with a diagnosis of an immune-mediated GI disease between 2002 and 2020 ("cases"). Those with a pre-existing eating disorder were excluded. Cases (n = 83,920) were matched with controls (n = 167,776) based on birth year, sex, and region of residence. Incidence rate ratio and hazard ratio were estimated using Poisson regression model and adjusted Cox proportional models, respectively. RESULTS: Over the follow-up period (up to January 31, 2022), 161 cases and 160 controls were identified with eating disorders. The overall incidence rate ratio (95% confidence interval, P -value) of eating disorders in immune-mediated GI disease was 1.99 (1.6-2.5, P < 0.001). The adjusted hazard ratio for eating disorder in cases with immune-mediated GI diseases was 1.98 (1.6-2.5, P < 0.001). In the pediatric group of incident cases (≤18 years of age), overall adjusted hazard ratio was 2.62 (1.9-3.7, P < 0.001) compared with 1.56 (1.02-2.4, P = 0.041) for adults (>18 years of age). The largest hazard ratio of 4.11 (1.6-10.3, P = 0.003) was observed for pediatric incident cases of ulcerative colitis. DISCUSSION: Inflammatory bowel disease and celiac disease are associated with the development of eating disorders. The magnitude of the association was stronger in the pediatric age group, underscoring the need for early screening and detection.

Lessons learned and new strategies for success: Evaluating the Implementation of Competency-Based Medical Education in Queen's Pediatrics.

Objectives: In 2017, Queen's University launched Competency-Based Medical Education (CBME) across 29 programs simultaneously. Two years post-implementation, we asked key stakeholders (faculty, residents, and program leaders) within the Pediatrics program for their perspectives on and experiences with CBME so far. Methods: Program leadership explicitly described the intended outcomes of implementing CBME. Focus groups and interviews were conducted with all stakeholders to describe the enacted implementation. The intended versus enacted implementations were compared to provide insight into needed adaptations for program improvement. Results: Overall, stakeholders saw value in the concept of CBME. Residents felt they received more specific feedback and monthly Competence Committee (CC) meetings and Academic Advisors were helpful. Conversely, all stakeholders noted the increased expectations had led to a feeling of assessment fatigue. Faculty noted that direct observation and not knowing a resident's previous performance information was challenging. Residents wanted to see faculty initiate assessments and improved transparency around progress and promotion decisions. Discussion: The results provided insight into how well the intended outcomes had been achieved as well as areas for improvement. Proposed adaptations included a need for increased direct observation and exploration of faculty accessing residents' previous performance information. Education was provided on the performance expectations of residents and how progress and promotion decisions are made. As well, "flex blocks" were created to help residents customize their training experience to meet their learning needs. The results of this study can be used to inform and guide implementation and adaptations in other programs and institutions.

Dedicated Assessors: description of an innovative education intervention to facilitate direct observation in the clinical setting.

BACKGROUND: The Department of Pediatrics at Queen's University undertook a pilot project in July 2017 to increase the frequency of direct observations (DO) its residents received without affecting the patient flow in a busy hospital-based pediatric ambulatory care clinic. Facilitating DO for authentic workplace-based assessments is essential for assessing resident's core competencies. The purpose of this study was to pilot an innovative education intervention to address the challenge of implementing DO in the clinical setting. METHODS: The project allowed for staff physicians to act as "dedicated assessors" (DA), a faculty member who was scheduled to conduct direct observations of trainees' clinical skills, while not acting as the attending physician on duty. At the end of the project, focus group interviews were conducted with faculty and residents, and thematic analysis was completed. RESULTS: Participants reported an increase in the overall quality of feedback received during the observations performed by a DA, with more specific feedback and a broader focus of assessment. There seemed to be little disruption to patient care. Some residents described the observations as anxiety-provoking. CONCLUSIONS: Overall, this project provides insight into an educational approach that medical residency programs can apply to increase the frequency of workplace-based DO and boost the quality of feedback residents receive while maintaining the flow of already busy ambulatory care clinics.

CONTEXTE: En juillet 2017, le département de pédiatrie de l'Université Queen's a lancé un projet pilote visant à augmenter la fréquence des observations directes (OD) dont faisaient l'objet ses résidents sans affecter le flux de patients dans une clinique achalandée de soins pédiatriques ambulatoires. Il est essentiel de faciliter l'OD, permettant une évaluation authentique en milieu de travail, afin d'évaluer les compétences fondamentales des résidents. L'objectif de cette étude était de piloter une intervention éducative novatrice pour relever le défi de la mise en place de l'OD dans le cadre clinique. MÉTHODES: Le projet permettait aux médecins d'agir en tant qu'« évaluateurs attitrés ¼ (ÉA) : c'est-à-dire un membre du corps professoral chargé de l'observation directe des compétences cliniques des apprenants alors qu'il n'était pas le médecin traitant de service. Une analyse thématique a été réalisée sur la base d'entrevues de groupe menées avec le corps professoral et les résidents à la fin du projet. RÉSULTATS: Les participants ont signalé une augmentation de la qualité générale de la rétroaction reçue au cours des observations effectuées par un ÉA, notamment des commentaires plus précis et une évaluation plus complète. Il semble y avoir eu peu de perturbations dans les soins aux patients. Certains résidents ont décrit les observations comme étant anxiogènes. CONCLUSIONS: Dans l'ensemble, ce projet donne un aperçu d'une approche éducative qui peut être appliquée dans le cadre des programmes de résidence en médecine dans le but d'augmenter la fréquence des OD en milieu de travail et d'améliorer la qualité de la rétroaction reçue par les résidents sans perturber le flux de patients dans les cliniques de soins ambulatoires déjà très achalandées.

Inflammatory Bowel Disease and Primary Sclerosing Cholangitis in a Pediatric Patient With Neurofibromatosis Type 1.

We describe a case of a 15-year-old adolescent boy with neurofibromatosis type 1 who presented with inflammatory bowel disease and primary sclerosing cholangitis. The literature available on the association of neurofibromatosis type 1 with inflammatory bowel disease is limited to 7 clinical case reports, and none had comorbid primary sclerosing cholangitis. We present a review of the published literature on this rare association and add the findings of our patient.

Severe alcohol intoxication among Canadian Youth: A 2-year surveillance study.

PURPOSE: To obtain data on Canadian youth, aged 11 to 15 years, presenting to paediatric emergency departments, with severe alcohol intoxication and to describe demographics, presentations to hospital, concurrent substance use, comorbidities, and short-term outcomes of admission to emergency departments. METHODS: Between March 2013 and February 2015, through the established methodology of the Canadian Paediatric Surveillance Program, Canadian paediatricians and paediatric subspecialists were surveyed monthly to identify cases of young adolescents presenting to paediatric emergency departments across Canada with severe alcohol intoxication. Those that identified cases were subsequently sent a detailed questionnaire. The detailed questionnaires were then screened to ensure the reported cases met the study's inclusion criteria. RESULTS: A total of 39 cases (18 females and 21 males) were included in the final analysis. Overall, results indicate over 90% of presenting youth had consumed spirits, 39% had concurrent substance use and 46% experienced serious medical morbidity. Almost two-thirds of youth were admitted to hospital for a period ranging from 10 hours to 5 days; 12 youth required intubation. Follow-up referrals were provided to two-thirds of youth, with variable supports given. No statistically significant differences between sexes were noted for blood alcohol level or concurrent substance use. CONCLUSION: Although rates of alcohol use in adolescents have been steadily decreasing, results from this surveillance study suggest that severe intoxication arising from the use of alcohol alone, and with concurrent substance use, results in significant immediate health consequences in young adolescents. Results from this study also highlight characteristics of patients, initial treatments and initial referrals across Canadian paediatric healthcare facilities, the results of which highlight variability and may aid in the guidance of a future longitudinal study, prevention strategies, and public health messaging.

Competence committee: How meeting frequency impacts committee function and learner-centered assessment.

The Department of Pediatrics at Queen's University wrestled with following the RCPSC guidelines with regards to Competence Committee (CC) meeting frequency, this article outlines adaptations we made to CC function and the rationale for our design decisions. After adopting a monthly meeting approach that focuses on formative assessment and greater resident feedback we have created an enhanced learner-centered assessment process that more fully empowers our residents with timely formative feedback to better support them in actively taking ownership of and responsibility for their learning.

Chronic, Gross Hematuria Caused by Idiopathic Ureteric Stricture.

An otherwise healthy, 10-year-old boy presented with chronic, gross hematuria. This persisted daily for 5 years despite extensive multidisciplinary workup with renal biopsy and resulted in severe iron deficiency anemia. The extensive workup and requirement for routine follow-up, investigations, and procedures led to significant psychosocial distress for the patient. Initially, it was thought the patient had a nutcracker phenomenon, but on closer inspection of his ureters, an idiopathic, unilateral ureteric stricture was discovered and, after 8 weeks of stenting, resulted in complete resolution of the hematuria. Importantly, the patient's psychosocial distress resolved after resolution of the hematuria and with the closure that came with a diagnosis.

Use of intranasal midazolam for manual separation of labial adhesions in the office.

Use of orally administered flavored midazolam elixir in the office setting has been previously described as an alternative to general anesthetic for manual separation of severe or persistent labial adhesions. We share the technique of using atomized intranasal midazolam for sedation (and amnesia) that has quicker onset, shorter duration, and well described safety and patient tolerance. This technique eliminates the problems associated with a child who refuses to swallow the elixir.

Accuracy of parents and health care professionals at estimating infant emesis volume.

OBJECTIVE: To quantify visual estimation inaccuracies of infant emesis by parents and caregivers (P/Cs) and health care professionals (HCPs). METHODS: A single-blinded survey was performed in which P/Cs and HCPs visually estimated predetermined volumes of simulated emesis spilled on receiving blankets or pyjamas. RESULTS: HCPs' estimations of volumes 1 and 3 were 150.4% and 145.1%, respectively, of the actual volumes, and their estimations of volumes 2 and 4 were 81.9% and 85.8%, respectively, of the actual volumes. This was, on average, significantly more accurate than the P/Cs' estimations (P<0.001 to P=0.002), which ranged from 130.4% to 275.7% of the actual volumes. CONCLUSION: P/Cs and HCPs were, on average, highly inaccurate at visually estimating simulated emesis volume, an important consideration when making clinical judgments based on these estimations. In addition, HCPs now have an evidence-based tool to use in their practice when reassuring and counselling anxious parents.

OBJECTIF: Quantifier les inexactitudes d'évaluation d'émésie des nourrissons par les parents et les personnes qui s'occupent d'eux (PPO) ainsi que par des professionnels de la santé (PdS). MÉTHODOLOGIE: Les chercheurs ont procédé à un sondage à simple insu au cours duquel des PPO et des PdS ont estimé visuellement des volumes prédéterminés d'émésie simulée sur des couvertures ou des pyjamas. RÉSULTATS: Les PdS ont évalué les volumes 1 et 3 à 150,4 % et à 145,1 % des volumes réels, respectivement, et les volumes 2 et 4 à 81,9 % et à 85,8 % des volumes réels, respectivement. En moyenne, ces réponses étaient considérablement plus précises que celles des PPO (P<0,001 à 0,002), qui se situaient entre 130,4 % et 275,7 % des volumes réels. CONCLUSION: En moyenne, les PPO et les PdS sont très imprécis lorsqu'ils évaluent visuellement un volume d'émésie simulée, une considération importante lorsqu'on pose des jugements cliniques selon ces estimations. Par ailleurs, les PdS possèdent désormais un outil probant à utiliser dans leur pratique lorsqu'ils rassurent et conseillent des parents anxieux.

Unnecessary irradiation to non-thoracic structures during pediatric chest radiography.

BACKGROUND: Recent reports have indicated that infants and young children have a higher sensitivity than older children and adults to radiation exposure and the potential for harmful side effects. OBJECTIVE: To determine whether the present landmarks used in film positioning result in unnecessary radiation to non-thoracic structures on chest radiographs in the pediatric and neonatal population. MATERIALS AND METHODS: Chest radiographs of 195 pediatric patients and 149 neonates were analyzed for extent of radiation field to non-thoracic regions. This was accomplished by delineating the most superior and inferior portions of the body included within the boundaries of collimation on each chest radiograph. The distance between the superior and inferior aspects of the lungs was measured and compared to the long axis of the radiation field on the radiograph. Radiographic reports were reviewed to determine whether valuable data were obtained from the imaging of these non-thoracic structures. RESULTS: The ratio of radiation exposure to non-thoracic structures increases as the age of the patient decreases. Overall, 43% of the length of the chest radiograph was of non-thoracic structures, resulting in radiation exposure to these sites. No significant information was gained in a single case by including the neck. In 3% of the neonatal patients, a potentially significant comment was reported on the abdomen included on the chest radiograph. CONCLUSION: Present positioning techniques in neonatal and pediatric chest radiography result in unnecessary radiation exposure to non-thoracic structures. New landmarks for collimation should be sought to eliminate this problem.

The Cockcroft-Gault formula should not be used in children.

BACKGROUND: Although designed for adults, the Cockcroft-Gault formula was recently proposed for use in children > or =13 years of age. METHODS: We compared the feasibility of the Cockcroft-Gault formula against the standard pediatric Schwartz formula and a novel cystatin C-based formula. Our patient cohort included 262 children aged 1 to 18 years with various renal pathologies, who underwent a 99-technetium diethylenetriaminepentaacetate ((99)Tc DTPA) glomerular filtration rate (GFR) renal scan. Calculations were performed in Systeme International (SI) units using published constants and recalculated constants from our patient population. Agreement was assessed using Bland and Altman analysis. RESULTS: Published and recalculated constants for the Cockcroft-Gault formula were 1.23 and 0.96, respectively, for boys, and 1.05 and 0.90, respectively, for girls. The published and recalculated constants for the Schwartz formula were 48 and 49.9, respectively, for boys > or =13 years old, and 38 and 46.2, respectively, for all girls and for boys <13 years old. Using published constants, there was agreement between GFR and Cockcroft-Gault formula in boys > or =13 years old (average bias 5.0 +/- 23.5%) while there was an average error of -19.0%+/- 36.4% for all ages. Similarly, the average bias with Schwartz for boys > or =13 years old was -6.8 +/- 24.0% and for all patients was -12.8 +/- 24.2%. Using recalculated constants, the average bias with Cockcroft-Gault in boys > or =13 years old was -19.8 +/- 23.5% and for all patients was -38.5 +/- 35.2%. Similarly, the average bias with Schwartz for boys < or =13 years old was -1.1 +/- 24.3% and for all patients was 3.0 +/- 24.0%. The novel cystatin C-based GFR calculations showed an average error of -4.9 +/- 20.3% in the adolescent boys and 2.4 +/- 20.4% for all ages. CONCLUSION: Cockcroft-Gault formula showed the worst agreement with GFR, regardless of using published or recalculated constants. The cystatin C-based approach resulted in the least error, and should be used for estimation of GFR.