Nicardipine or Nitroprusside for Postoperative Blood Pressure Control in Infants After Surgery for Congenital Heart Disease: Single-Center Retrospective Noninferiority and Cost Analysis, 2016-2020.

OBJECTIVES: Postoperative hypertension frequently occurs after surgery for congenital heart disease. Given safety concerns when using calcium channel blockers in infants along with the cost and side-effect profile of nitroprusside, we retrospectively assessed our experience of using nicardipine and nitroprusside for postoperative blood pressure control in infants who underwent surgery for congenital heart disease. We also investigated the cost difference between the medications. DESIGN: This study was a single-center retrospective, pre-post chart review of patients who had surgery for congenital heart disease between 2016 and 2020. The primary aim was a noninferiority comparison of achievement of blood pressure goal at 1-hour post-initiation of an antihypertensive agent. Secondary comparisons included achievement of blood pressure goal at 2 hours after medication initiation, Vasoactive-Inotropic Score (VIS), and blood transfusion, crystalloid volume, and calcium needs. SETTING: Academic quaternary-care center. PATIENTS: Infants under 1 year old who required treatment for hypertension with nitroprusside ( n = 71) or nicardipine ( n = 52) within 24 hours of surgery for congenital heart disease. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: We failed to identify any difference in proportion of patients that achieved blood pressure control at 1-hour after medication initiation (nitroprusside 52% vs. nicardipine 54%; p = 0.86), with nicardipine noninferior to nitroprusside within a 15% margin. Of patients who did not achieve control at 1-hour post-medication initiation, receiving nicardipine was associated with blood pressure control at 2 hours post-medication initiation (79% vs. 38%; p = 0.003). We also failed to identify an association between antihypertensive types and mean VIS scores, blood transfusion volumes, crystalloid volumes, and quantities of calcium administered. Index cost of using nitroprusside was 16 times higher than using nicardipine, primarily due to difference in wholesale cost. CONCLUSIONS: In our experience of achieving blood pressure control in infants after surgery for congenital heart disease (2016-2020), antihypertensive treatment with nicardipine was noninferior to nitroprusside. Furthermore, nicardipine use was significantly less expensive than nitroprusside. Our contemporary practice is therefore to use nicardipine in preference to nitroprusside.

Lower Maternal Chronic Physiological Stress and Better Child Behavior at 18 Months: Follow-Up of a Cluster Randomized Trial of Neonatal Intensive Care Unit Family Integrated Care.

OBJECTIVE: To assess whether Family Integrated Care (FICare) in the neonatal intensive care unit improves maternal chronic physiological stress and child behavior at 18 months of corrected age for infants born preterm. STUDY DESIGN: Follow-up of a multicenter, prospective cluster-randomized controlled trial comparing FICare and standard care of children born at <33 weeks of gestation and parents, stratified by tertiary neonatal intensive care units, across Canada. Primary outcomes at 18 months of corrected age were maternal stress hormones (cortisol, ie, hair cumulative cortisol [HCC], dehydroepiandrosterone [DHEA]) assayed from hair samples. Secondary outcomes included maternal reports of parenting stress, child behaviors (Internalizing, Externalizing, Dysregulation), and observer-rated caregiving behaviors. Outcomes were analyzed using multilevel modeling. RESULTS: We included 126 mother-child dyads from 12 sites (6 FICare sites, n = 83; 6 standard care sites, n = 43). FICare intervention significantly lowered maternal physiological stress as indicated by HCC (B = -0.22 [-0.41, -0.04]) and cortisol/DHEA ratio (B = -0.25 [-0.48, -0.02]), but not DHEA (B = 0.01 [-0.11, 0.14]). Enrollment in FICare led to lower child Internalizing (B = -0.93 [-2.33, 0.02]) and Externalizing behavior T scores (B = -0.91 [-2.25, -0.01]) via improvements to maternal HCC (mediation). FICare buffered the negative effects of high maternal HCC on child Dysregulation T scores (B = -11.40 [-23.01, 0.21]; moderation). For mothers reporting high parenting stress at 18 months, FICare was related to lower Dysregulation T scores via maternal HCC; moderated mediation = -0.17 (-0.41, -0.01). CONCLUSIONS: FICare has long-term beneficial effects for mother and child, attenuating maternal chronic physiological stress, and improving child behavior in toddlerhood. CLINICAL TRIAL REGISTRATION: NCT01852695.

Inhaled corticosteroid prescriptions in the ED for recurrent asthma using IT clinical decision support: revisit after cessation of an incentive program.

INTRODUCTION: The objective of this study was to assess whether inhaled corticosteroid (ICS) prescription rates for patients with poorly controlled asthma presenting to the emergency department (ED) remained high with a clinical support system in place, after a financial incentive program ended. This study is the second phase of a previous study done at our institution. The first phase demonstrated that the introduction of an electronic alert system advising providers to prescribe ICS to patients with poorly controlled asthma, along with a financial incentive, increased ICS prescription rates from 2% to 77%. Clinical support systems are necessary to improve control for patients with asthma, as prescribing ICS in the ED has not previously been standard of care. METHODS: This retrospective study identified 96 eligible patients during the study period of January 1, 2019 to December 31, 2019. Subjects included patients aged 4-18 with at least two ED visits for asthma within 365 days and no recent ICS prescription. For subjects meeting these criteria, an electronic alert activated, advising the provider to prescribe ICS. RESULTS: ICS prescription rate without the incentive remained high at 0.74 (0.59, 0.86) and was not significantly different than the rate with the incentive of 0.77 (0.65, 0.87), with p value 0.82. No significant differences were detected in baseline characteristics between patients discharged with and without an ICS prescription. CONCLUSIONS: This study confirmed that an electronic alert advising ICS prescription in the ED for patients with recurrent asthma visits is effective, even without a financial incentive.

Pediatric Emergency Department Return Visits Within 72 Hours: Caregivers' Motives and Analysis of Ethnic and Primary Language Disparities.

OBJECTIVES: In the United States, approximately 2.2% to 5% of children discharged from the emergency department (ED) return within 72 hours. There is limited literature examining caregivers' reasons for return to the ED, and none among Hispanics and Spanish-speaking caregivers. We sought to examine why caregivers of pediatric patients return to the ED within 72 hours of a prior ED visit, and assess roles of ethnicity and primary language. METHODS: A previously validated survey was prospectively administered to caregivers returning to the ED within 72 hours of discharge at a freestanding, tertiary care, children's hospital over a 7-month period. Reasons for return to the ED, previous ED discharge processes, and events since discharge were summarized according to Hispanic ethnicity, and English or Spanish language preference, and compared using the Fisher exact test. RESULTS: Among 499 caregiver surveys analyzed, caregivers returned mostly because of no symptom improvement (57.5%) and worsening condition (35.5%), with no statistically significant differences between Hispanic/non-Hispanic ethnicity, or English/Spanish preference. Most (85.2%) caregivers recalled reasons to return to the ED. Recall of expected duration until symptom improvement was significantly higher among Hispanic (60.4%) versus non-Hispanic (52.1%) (P = 0.003), and for Spanish- (68.9%) versus English-speaking (54.6%) (P = 0.04), caregivers. CONCLUSIONS: Most caregivers returned to the ED because their child's condition was not better or had worsened. Ethnicity and language were not associated with variations in reasons for return. Non-Hispanic and English-speaking caregivers were less likely to recall being informed of time to improvement and may require additional intervention.

Annual Mammographic Screening Reduces the Risk of Interval or Higher Stage Invasive Breast Cancers Among Postmenopausal Women in the Ontario Breast Screening Program.

Purpose: In the Ontario Breast Screening Program (OBSP) annual screening improved breast cancer detection for women 50-74 years with a family/personal history compared to biennial, while detection was equivalent for women screened annually for mammographic density ≥75%. This study compares the risk of interval or higher stage invasive cancers among postmenopausal women screened annually vs biennially by age and estrogen use. Methods: A retrospective design identified 4247 invasive breast cancers diagnosed among concurrent cohorts of women 50-74 screened in the OBSP with digital mammography between 2011 and 2014, followed until 2016. Polytomous logistic regression estimated the risk of interval or higher stage breast cancers by age and estrogen use between women screened annually because of first-degree relative with breast or ovarian cancer or personal history of ovarian cancer, or mammographic density ≥75%, and those screened biennially. Results: The risk of interval vs screen-detected cancers was significantly reduced in women screened annually for family/personal history (OR=.64; 95%CI:0.51-.80), particularly those 60-74 years (OR=.59; 95%CI:0.45-.77) or not currently using estrogen (OR=.66; 95%CI:0.52-.83) compared to those screened biennially. The risk of stage II-IV vs stage I tumors was also lower in women 60-74 years screened annually for family/personal history (OR=.79; 95%CI:0.64-.97) and in those screened annually for mammographic density ≥75% currently using estrogen (OR=.51; 95%CI:0.26-1.01) compared to women screened biennially. Conclusion: Postmenopausal women at increased risk screened annually had equivalent or reduced risks of interval or higher stage invasive breast cancers than those screened biennially, further supporting risk-based screening in this population.

Network-targeted approach and postoperative resting-state functional magnetic resonance imaging are associated with seizure outcome.

OBJECTIVE: Postoperative resting-state functional magnetic resonance imaging (MRI) in children with intractable epilepsy has not been quantified in relation to seizure outcome. Therefore, its value as a biomarker for epileptogenic pathology is not well understood. METHODS: In a sample of children with intractable epilepsy who underwent prospective resting-state seizure onset zone (SOZ)-targeted epilepsy surgery, postoperative resting-state functional MRI (rs-fMRI) was performed 6 to 12 months later. Graded normalization of the postoperative resting-state SOZ was compared to seizure outcomes, patient, surgery, and anatomical MRI characteristics. RESULTS: A total of 64 cases were evaluated. Network-targeted surgery, followed by postoperative rs-fMRI normalization was significantly (p < 0.001) correlated with seizure reduction, with a Spearman rank correlation coefficient of 0.83. Of 39 cases with postoperative rs-fMRI SOZ normalization, 38 (97%) became completely seizure free. In contrast, of the 25 cases without complete rs-fMRI SOZ normalization, only 3 (5%) became seizure free. The accuracy of rs-fMRI as a biomarker predicting seizure freedom is 94%, with 96% sensitivity and 93% specificity. INTERPRETATION: Among seizure localization techniques in pediatric epilepsy, network-targeted surgery, followed by postoperative rs-fMRI normalization, has high correlation with seizure freedom. This study shows that rs-fMRI SOZ can be used as a biomarker of the epileptogenic zone, and postoperative rs-fMRI normalization is a biomarker for SOZ quiescence. ANN NEUROL 2019;86:344-356.

Volumetrics and fit assessments for donor to recipient size matching in pediatric heart transplantation: Is it time for a new paradigm?

Pediatric heart transplant patients face the highest waitlist mortality in solid organ transplantation. Given the relatively fixed number of donor organs becoming available each year, improving donor organ utilization could potentially have significant impact on reducing waitlist mortality. Donor to recipient weight ratio has historically been used to identify suitable donors; however, this method does not take into account the potential for significant variance in heart size due to complex congenital heart disease or underlying cardiomyopathy. We believe, based on our experience to date, that donor matching based upon weight ratios should be augmented by improved methodologies that provide a more accurate assessment of heart volumes. Herein we describe the rationale for these methodologies and our single-center experience using volumetrics as an alternative for donor fit assessments.

Inhaled corticosteroids prescriptions increased in the ED for recurrent asthma exacerbations by automated electronic reminders in the ED.

Objective: The objective of this study was to evaluate the impact of an electronic alert on the prescription rate of inhaled corticosteroids (ICS) by ED providers for poorly controlled persistent asthmatic children.Methods: Study subjects included asthmatic patients age 4-18 presenting to the ED at Phenix Children's Hospital between February 9, 2018 and December 4, 2018, with a history of at least two previous ED visits for acute exacerbation of asthma within 365 days, no active ICS prescription within 90 days, and free from developmental delay, bronchopulmonary dysplasia due to prematurity, cystic fibrosis, sickle cell disease, and/or interstitial ling disease. Patients meeting these criteria triggered an electronic alert prompting the medical provider to prescribe ICS or indicate reason for not prescribing. Instruction on the alert was provided to ED attending physicians and residents by email and through several educational sessions held prior to the implementation.Results: Among 62 patients without prior ICS who were discharged home from the ED, ICS was prescribed for 48 (77%). No statistically significant differences were detected in baseline characteristics between patients discharged home from the ED with and without ICS prescription. While ICS was prescribed by a larger proportion of physicians (56%) compared to residents (42%), statistical significance was not reached. For the 14 (33%) patients who were discharged home without ICS, no reason was provided to indicate why ICS were not prescribed.Conclusion: An electronic alert incorporated into the ED workflow to populate a discharge order set is effective to initiate asthma controller medication for poorly controlled pediatric patients. Additional data describing reasons for not prescribing ICS can further refine recommendations for ICS prescriptions, and provide a comprehensive strategy to support clinical decision for pediatric asthma control in acute care settings.

Trends in adult patients presenting to pediatric emergency departments.

OBJECTIVE: Adults presenting to pediatric emergency departments (PEDs) include those with complex chronic conditions (CCCs) often still followed by pediatric providers, and those without CCCs (non-CCCs). This paper describes recent trends in adults seen within PEDs, both by age subgroups and CCC status. METHODS: Data were retrospectively reviewed from the Pediatric Health Information System for PED visits between Jan 1, 2013 and Dec 31, 2017. Yearly visit rates were trended for all adult visits, age subgroups (18-21, 22-25, 26-40, and 41-95 years), and by CCC status. The most frequent diagnoses were reviewed for each adult age group and CCC category. RESULTS: Rates of adult PED visits significantly increased from 3.7% in 2013 to 4.2% in 2017 (P < 0.0001). While the overall majority (88% overall and >70% for each age group) of adult PED patients were non-CCC, the rate of CCC patients increased overall (P < 0.0001), especially among older patients (41-95 years) from 8.7% in 2013 to 29% in 2017 (P < 0.0001). The most frequent CCC diagnoses were sickle cell disease (18-21 and 22-25 years), cardiac pathology (26-40 years), and hyperlipidemia (41-95 years). The most frequent non-CCC diagnoses were abdominal pain (18-21 years), pregnancy-related (22-25 and 26-40 years), and chest pain (41-95 years). CONCLUSION: Visits to PEDs by adult patients have increased over time, with the majority of the population being represented by non-CCC adults. The results of this study can be used to guide specifics in adult medicine training during Pediatric Emergency Medicine fellowship and assist in continuing education efforts.

Use of dual lumen ports for red blood cell exchange: A comparison of adults and children with sickle cell disease.

PURPOSE: Sickle cell patients receiving chronic RBC exchange require a form of long-term central venous access if peripheral access is inadequate. In adults, dual lumen (DL) ports have been utilized but associated with greater procedure complications and duration when compared to other forms of access. In the pediatric sickle cell population, the use of DL ports for RBC exchange has not been well described. In this retrospective cohort study, RBC exchange procedures utilizing DL ports in the pediatric vs adult sickle cell population were compared. METHODS: Medical records were reviewed for 685 RBC exchange procedures performed on 25 patients (11 pediatric and 14 adult) between November 2014 to November 2018. Patient-level characteristics and outcomes were compared between pediatric and adult patients using the Fisher-exact and Wilcoxon-rank sum test. Linear/logistic regression models examined procedure-level parameters and port characteristics with adjustment for clustering. RESULTS: Compared to adults, pediatric patients had slower average maximum inlet speed (42 vs 53 mL/min, P < .01), but shorter procedure time (60 vs 75 minutes, P < .01) and lower rate of access alarms (1% vs 11%, P < .01). Overall, 0.29 thrombotic events per 1000 port days and 0.04 infections per 1000 port days were observed. CONCLUSION: For adult and pediatric sickle cell patients, a DL port provides a viable option for RBC exchange. In comparison to adults, pediatric procedures with a DL port will typically be shorter and with less procedural complications due to smaller blood volumes and lower flow requirements.

Metformin as Adjunctive Therapy for Pediatric Patients With Hidradenitis Suppurativa.

BACKGROUND: Hidradenitis suppurativa (HS) is a chronic inflammatory disorder seen in adolescents and adults characterized by abscesses, sinus tracts and scarring, typically affecting intertriginous skin. Treatments often provide suboptimal control of the disease, and there are limited reports of therapies utilized in the pediatric population. There are no published guidelines or consensus for the treatment of pediatric HS. PURPOSE: To evaluate the clinical efficacy and safety of metformin as adjunctive treatment in adolescent patients with HS who have not responded to standard therapies at a single institution. RESULTS: Retrospective chart review identified 16 pediatric patients treated with metformin as adjunctive therapy for HS. Baseline scores were Hurley 1 in eleven (69%) and Hurley 2 in five (31%) patients. Follow-up visit data showed six (67%) patients were Hurley 1 and three (33%) patients were Hurley 2; five patients showed improvement on metformin with decreased frequency of flares, and five patients had no improvement. Six patients were lost to follow up or data was not available. Two patients discontinued metformin therapy due to side effects, including gastrointestinal distress and mood changes; the third patient discontinued due to lack of improvement. Two patients had mildly elevated liver transaminases prior to metformin initiation which improved while on metformin therapy. DISCUSSION: For some pediatric patients, metformin as an adjunctive therapy may help improve control of HS with minimal side effects. Adequately designed and controlled studies are needed to further evaluate the role of metformin, and efficacy, tolerability and safety in the pediatric HS patients. J Drugs Dermatol. 2020;19(12): doi:10.36849/JDD.2020.5447.

Effect of Dietary Flaxseed Intake on Circulating Sex Hormone Levels among Postmenopausal Women: A Randomized Controlled Intervention Trial.

Lignan intake, and its richest food source, flaxseed, have been associated with reduced breast cancer risk. Endogenous sex hormones, such as estrogens, play a role in breast cancer development, and lignans may alter these sex hormone levels. To assess the effect of flaxseed on circulating sex hormones, a randomized controlled trial was conducted among 99 postmenopausal women in Toronto, Canada. The intervention arm consumed 2 tablespoons (15 g) of ground flaxseed daily for 7 weeks; the control arm maintained usual diet. Baseline and week 7 concentrations of 14 serum sex hormones were measured using liquid chromatography-tandem mass spectrometry (LC-MS/MS) and immunoassay, and serum enterolignans (lignan biomarker) using LC-MS/MS. Intervention effects on sex hormone levels were assessed using analysis of covariance. Serum enterolignans increased among the flaxseed arm (+516%). Women consuming flaxseed (vs. controls) had increased serum 2-hydroxyestrone [treatment effect ratio (TER) = 1.54; 95% CI: 1.18-2.00] and 2:16α-hydroxyestrone ratio (TER =1.54; 95% CI: 1.15-2.06); effects on other hormones were not statistically significant. Within the flaxseed arm, change in enterolignan level was positively correlated with changes in 2-hydroxyestrone and 2:16α-hydroxyestrone ratio, and negatively with prolactin. Findings suggest flaxseed affects certain circulating sex hormone levels with possible implications for future breast cancer prevention research.

Adolescent male fertility following reduced-intensity conditioning regimen for hematopoietic stem cell transplantation in non-malignant disorders.

INTRODUCTION: The effects of RIC for HSCT on male fertility remain unknown. We investigated spermatogenesis and gonadal hormonal status among adolescent male patients who received RIC HSCT for non-malignant diseases. PATIENTS AND METHODS: Patients with non-malignant disease who had undergone a RIC HSCT were recruited and evaluated for spermatogenesis via semen analysis and gonadal hormonal function via serum hormone levels. Those who had received prior chemotherapy or radiation were excluded from the study. We reviewed the charts to record demographic factors, conditioning regimen and complications during and after transplant. RESULTS: Five patients were enrolled. The median age at the time of transplant was 15 years (range, 11-19 years), and the median time between bone marrow transplant and semen analysis was 5 years (range, 3-11 years). Median age of patients was 20 years (range, 18-25 years) at the time of the study. Serum FSH and LH levels were elevated in four patients, and inhibin B levels were low for age in three patients. Semen analysis showed two patients had azoospermia, and the remaining three patients showed severe oligozoospermia. Normal morphology and motility were seen in only one patient. CONCLUSION: This case series suggests that RIC transplants may be associated with impaired spermatogenesis and sequential follow-up is necessary given the potential for either permanent impairment or delayed recovery. Further larger studies are needed to confirm these findings.

Outcomes of Surgical Ligation after Unsuccessful Pharmacotherapy for Patent Ductus Arteriosus in Neonates Born Extremely Preterm.

A retrospective cohort study of neonates born extremely preterm with persistent patent ductus arteriosus after unsuccessful pharmacologic closure compared outcomes between 166 surgically ligated and 142 nonligated neonates. After adjustment for confounders, ligation was not associated with the composite outcome of death or neurodevelopmental impairment, neurodevelopmental impairment alone, chronic lung disease, or retinopathy of prematurity among survivors.

Vitamin D deficiency and outcomes in pediatric hematopoietic stem cell transplantation.

BACKGROUND: Pediatric patients undergoing hematopoietic stem cell transplantation (HSCT) are frequently diagnosed with vitamin D deficiency, which may impact outcomes. OBJECTIVES: To estimate the prevalence of vitamin D deficiency and examine its association with short-term survival in pediatric HSCT patients. METHODS: Patients undergoing HSCT at Phoenix Children's Hospital were retrospectively identified. Routine serum 25-hydroxyvitamin D measurements were described prior to transplant and at 100 days and 1-year post-HSCT. Associations of pre-HSCT vitamin D groups (i.e., normal ≥30 ng/ml, insufficient 20-29 ng/ml, and deficient <30 ng/ml) with demographics, clinical factors, and outcomes were examined using nonparametric tests and Cox proportional hazards analyses. RESULTS: Among 72 study subjects, the median vitamin D pre-HSCT was 26 ng/ml (range: 19-34 ng/ml). Levels were insufficient and deficient in 25 (35%) and 20 (28%) patients, respectively, with only two (3%) patients on supplemental therapy pre-HSCT. Despite supplemental therapy provided to 46 (74%) subjects, insufficient/deficient rates did not significantly change between pre-HSCT and 100 days post-HSCT, but mean vitamin D levels significantly increased by 1-year post-HSCT (P = 0.01).Vitamin D pre-HSCT was not associated with the development of acute or chronic graft-versus-host disease (GVHD) or delayed engraftment. Overall 1-year survival was significantly lower for patients with deficient (65%) compared to normal (93%) pre-HSCT vitamin D (P = 0.001). CONCLUSION: Suboptimal vitamin D levels are common in pediatric patients scheduled to receive HSCT and are associated with lower overall 1-year survival. Further study is warranted to delineate the mechanisms underlying the role of vitamin D in successful HSCT.

Asthma treatment and outcomes for children in the emergency department and hospital.

OBJECTIVE: To describe and compare the treatment of acute asthma exacerbations in children given in the emergency department (ED) and admitted to acute care floor in the hospital or intensive care unit (ICU). METHODS: A retrospective chart review of visits for acute exacerbation of asthma treated at Phoenix Children's Hospital between January 1, 2014 and December 31, 2016. RESULTS: A total of 287 asthma exacerbation cases were identified including 106 (37%) ED visits, 134 (47%) hospital floor and 47 (16%) ICU admissions. A history of a previous ED visit (ED 88%, Floor 60% and ICU 68%; p < 0.0001) and prior pulmonology inpatient consultation (ED 30%, Floor 19% and ICU 15%; p = 0.05) varied significantly. Pulmonology inpatient consultations were performed more frequently in the ICU than on the hospital floor (54% versus 8%; p < 0.0001). Although overall 145 (51%) of the cases were already on inhaled corticosteroids (ICS) at the time of visit with no differences across locations, ICS initiation/step-up was greater in the ICU (72%) than on the hospital floor (54%) and ED (2%) (p < 0.0001). A recommendation given to the family for follow-up with pulmonology was more frequent for patients who had been admitted to the ICU (68%) as compared to those only admitted to the floor (31%) or ED (4%) (p < 0.0001). Readmission rates were similar for patients previously admitted to the hospital (Floor 42%; ICU 40%), but significantly higher for previous ED visits (77%) (p < 0.0001). CONCLUSIONS: Physicians in the ED have an opportunity to provide preventative care in the acute care setting and should be encouraged to initiate treatment with ICS. Consideration should be given to develop a program or clinical pathway focused on long-term asthma management and maintenance to reduce readmissions and long hospital stays.

Evaluating wait times from screening to breast cancer diagnosis among women undergoing organised assessment vs usual care.

BACKGROUND: Timely coordinated diagnostic assessment following an abnormal screening mammogram reduces patient anxiety and may optimise breast cancer prognosis. Since 1998, the Ontario Breast Screening Program (OBSP) has offered organised assessment through Breast Assessment Centres (BACs). For OBSP women seen at a BAC, an abnormal mammogram is followed by coordinated referrals through the use of navigators for further imaging, biopsy, and surgical consultation as indicated. For OBSP women seen through usual care (UC), further diagnostic imaging is arranged directly from the screening centre and/or through their physician; results must be communicated to the physician who is then responsible for arranging any necessary biopsy and/or surgical consultation. This study aims to evaluate factors associated with diagnostic wait times for women undergoing assessment through BAC and UC. METHODS: Of the 2 147 257 women aged 50-69 years screened in the OBSP between 1 January 2002 and 31 December 2009, 155 866 (7.3%) had an abnormal mammogram. A retrospective design identified two concurrent cohorts of women diagnosed with screen-detected breast cancer at a BAC (n=4217; 47%) and UC (n=4827; 53%). Multivariable logistic regression analyses examined associations between wait times and assessment and prognostic characteristics by pathway. A two-sided 5% significance level was used. RESULTS: Screened women with breast cancer were two times more likely to be diagnosed within 7 weeks when assessed through a BAC vs UC (OR=1.91, 95% CI=1.73-2.10). In addition, compared with UC, women assessed through a BAC were significantly more likely to have their first assessment procedure within 3 weeks of their abnormal mammogram (OR=1.25, 95% CI=1.12-1.39), ⩽3 assessment procedures (OR=1.54, 95% CI=1.41-1.69), ⩽2 assessment visits (OR=1.86, 95% CI=1.70-2.05), and ⩾2 procedures per visit (OR=1.41, 95% CI=1.28-1.55). Women diagnosed through a BAC were also more likely than those in UC to have imaging (OR=1.99, 95% CI=1.44-2.75) or a biopsy (OR=3.69, 95% CI=2.64-5.15) vs consultation only at their first assessment visit, and two times more likely to have a core or FNA biopsy than a surgical biopsy (OR=2.08, 95% CI=1.81-2.40). Having ⩽2 assessment visits was more likely to reduce time to diagnosis for women assessed through a BAC compared with UC (BAC OR=10.58, 95% CI=8.96-12.50; UC OR=4.47, 95% CI=3.94-5.07), as was having ⩽3 assessment procedures (BAC OR=4.97, 95% CI=4.26-5.79; UC OR=2.95, 95% CI=2.61-3.33). Income quintile affected wait times only in women diagnosed in UC, with those in the two highest quintiles more likely to receive a diagnosis in 7 weeks. CONCLUSIONS: Women with screen-detected breast cancer in OBSP were more likely to have shorter wait times if they were diagnosed through organised assessment. This might be as a result of women diagnosed through a BAC having more procedures per visit, procedures scheduled in shorter intervals, and imaging or biopsy on their first visit. Given the significant improvement in timeliness to diagnosis, women with abnormal mammograms should be managed through organised assessment.

Trends and Outcomes of Patent Ductus Arteriosus Treatment in Very Preterm Infants in Canada.

Objective To assess trends in patent ductus arteriosus (PDA) management and examine concurrent changes in neonatal mortality and morbidities. Methods This retrospective observational study examined infants born at 23 to 32 weeks' gestational age with PDA and admitted to a neonatal unit during 2006 to 2012. Multivariable logistic regression assessed trends in yearly PDA treatment rates and compared a composite outcome of mortality or any severe morbidity (bronchopulmonary dysplasia, intraventricular hemorrhage, periventricular leukomalacia, retinopathy of prematurity, or necrotizing enterocolitis) between and within time periods and PDA treatments. Results Study subjects included 5,824 preterm neonates with clinical/echocardiographic PDA diagnosis. During 2006 to 2012, conservative management increased (14-38%), whereas pharmacotherapy-only (58-49%), surgical ligation-only (7.1-2.5%), and both pharmacotherapy and surgical ligation (21-10%) decreased (p-values <0.01). From 2006 to 2008 and 2009 to 2012, the composite outcome decreased for infants managed conservatively (AOR = 0.70, 95% CI 0.52-0.92), with no changes detected for pharmacotherapy and/or ligation. Lower composite outcome after conservative management versus pharmacotherapy-only during 2009 to 2012 (AOR = 0.61, 95% CI 0.51-0.74), but not during 2006 to 2008 reflect significant effect modification by time period. Conclusion In Canada, during 2006 to 2012, conservative PDA management increased while pharmacotherapy and/or surgical ligation decreased. Lower composite outcome was detected during later years after increases in conservative management; however, bias due to unmeasured confounders remains possible.

Lead Time to Appointment and No-Show Rates for New and Follow-up Patients in an Ambulatory Clinic.

High rates of no-shows in outpatient clinics are problematic for revenue and for quality of patient care. Longer lead time to appointment has variably been implicated as a risk factor for no-shows, but the evidence within pediatric clinics is inconclusive. The goal of this study was to estimate no-show rates and test for association between appointment lead time and no-show rates for new and follow-up patients. Analyses included 534 new and 1920 follow-up patients from pulmonology and gastroenterology clinics at a freestanding children's hospital. The overall rate of no-shows was lower for visits scheduled within 0 to 30 days compared with 30 days or more (23% compared with 47%, P < .0001). Patient type significantly modified the association of appointment lead time; the rate of no-shows was higher (30%) among new patients compared with (21%) follow-up patients with appointments scheduled within 30 days (P = .004). For appointments scheduled 30 or more days' lead time, no-show rates were statistically similar for new patients (46%) and follow-up patients (0.48%). Time to appointment is a risk factor associated with no-shows, and further study is needed to identify and implement effective approaches to reduce appointment lead time, especially for new patients in pediatric subspecialties.