Validation of Patient-Reported Outcome measure in pediatric chronic Kidney disease (PRO-Kid).

BACKGROUND: Measuring the burden of symptoms that matter most to children and adolescents with chronic kidney disease (CKD) is essential for optimizing patient-centered care. We developed a novel CKD-specific Patient-Reported Outcome measure (PRO-Kid) to assess both frequency and impact of symptoms in children. In the current study, we further assessed the validity and internal consistency of PRO-Kid. METHODS: In this multicenter study, children age 8 to 18 years with stages 3-5 CKD, including those on dialysis, were recruited from five pediatric centers. Children completed the 14-item PRO-Kid questionnaire and the validated Pediatric Quality of Life Inventory (PedsQL™ 4.0). We explored the dimensionality of the PRO-kid scale using exploratory and confirmatory factor analysis, to either establish that it is a unidimensional construct or identify evidence of subfactors. We then assessed internal consistency (Cronbach's alpha [Cα]) and construct validity (Pearson correlations). RESULTS: In total, 100 children were included. The median eGFR was 27.4 ml/min/1.73m2 [7.43, 63.4], and 26 children (26%) were on dialysis. Both the PRO-Kid frequency and the impact scales were unidimensional. Cα was high for both the PRO-Kid frequency and impact scales, 0.83 (95% CI = 0.78 to 0.88) and 0.84 (95% CI = 0.80 to 0.89) respectively, showing strong internal consistency. Pearson correlations between PRO-Kid and PedsQL™ scores were also strong: -0.78 (95% confidence interval [CI] = -0.85 to -0.70) for the frequency score and -0.69 (95% CI = -0.78 to -0.56) for the impact score, reflecting the association between poorer quality of life and higher symptom burden. CONCLUSIONS: PRO-Kid is a novel patient-reported symptom burden tool for children 8-18 years of age with CKD that correlates strongly in the expected direction with PedsQL™, supporting its validity. Future work will evaluate changes in PRO-Kid score with progression of CKD, and implementation of the tool into clinical care.

Identification of four latent classes of acute respiratory distress syndrome using PaO2/FIO2 ratio: an observational cohort study.

Biological phenotypes in patients with the acute respiratory distress syndrome (ARDS) have previously been described. We hypothesized that the trajectory of PaO2/FIO2 ratio could be used to identify phenotypes of ARDS. We used a retrospective cohort analysis of an ARDS database to identify latent classes in the trajectory of PaO2/FIO2 ratio over time. We included all adult patients admitted to an intensive care unit who met the Berlin criteria for ARDS over a 4-year period in tertiary adult intensive care units in Manitoba, Canada. Baseline demographics were collected along with the daily PaO2/FIO2 ratio collected on admission and on days 1-7, 14 and 28. We used joint growth mixture modeling to test whether ARDS patients exhibit distinct phenotypes with respect to both longitudinal PaO2/FIO2 ratio and survival. The resulting latent classes were compared on several demographic variables. In our study group of 209 patients, we found that four latent trajectory classes of PaO2/FIO2 ratio was optimal. These four classes differed in their baseline PaO2/FIO2 ratio and their trajectory of improvement during the 28 days of the study. Despite similar baseline characteristics the hazard for death for the classes differed over time. This difference was largely driven by withdrawal of life sustaining therapy in one of the classes. Latent classes were identified in the trajectory of the PaO2/FIO2 ratio over time, suggesting the presence of different ARDS phenotypes. Future studies should confirm the existence of this finding and determine the cause of mortality differences between classes.

Early life adversity and obesity risk in adolescence: a 9-year population-based prospective cohort study.

BACKGROUND: There are few prospective studies of factors that mediate the association between exposure to adverse childhood experiences (ACEs) and obesity in adolescence. Our aim was to address this limitation. METHODS: We used prospective data from the Growing up in Ireland cohort study, with measurements at 9, 13, and 18 years old. The exposures were 14 adverse experiences before age 9. The main outcome was body mass index (BMI) at 18 years. Mediators were daily activity, diet quality, self-image and behavioural difficulties at 13 years. RESULTS: Among the 4561 adolescents in the final cohort, 77.2% experienced any adversity, 50.5% were female and 26.7% were overweight/obese at 18 years. BMI Z was higher at ages 9 (0.54 vs 0.43, p < 0.05, 95% CI of difference: -0.22, -0.01) and 13 years (0.50 vs 0.35, p < 0.05, 95% CI of difference: -0.25, -0.06), in those exposed to an ACE, compared to those unexposed. Structural equation models revealed that behavioural difficulties (ß = 0.01; 95% CI: 0.007-0.018, p < 0.001) and self-concept (ß = 0.0027; 95% CI: 0.0004-0.0050, p = 0.026) indirectly mediate the association between exposure to ACEs and BMI at 18 years. CONCLUSIONS: The association between ACEs and BMI in adolescence is mediated by behavioural difficulties and self-concept. IMPACT: In a previous study, we found modest associations between exposure to a range of adverse childhood experiences and weight gain at 13 years of age. The strength of the association between adverse childhood experiences and weight gain was lower at 18 years of age compared to the association observed at 13 years and was no longer significant after controlling for confounding and including possible mediators. The association between adverse childhood experiences and BMI in adolescence is indirectly mediated by behavioural difficulties and self-concept.

Factors Affecting Quality of Life in Adolescents Living With Type 2 Diabetes: A Substudy of the Improving Renal Complications in Adolescents With Type 2 Diabetes Through REsearch (iCARE) Cohort.

OBJECTIVES: Type 2 diabetes (T2D) disproportionately impacts adolescents living in challenging socioeconomic conditions. However, the impacts of T2D on quality of life (QOL) in this context are unknown. Our aim in this study was to evaluate QOL and identify its biological, psychological, and social determinants among adolescents living with and without T2D from similar sociodemographic backgrounds. Relationships between glycemic stability, early complications, and treatments of T2D and QOL were also examined. METHODS: Ninety-two adolescents with T2D and 59 at-risk controls were included from the Improving Renal Complications in Adolescents With Type 2 Diabetes Through Research (iCARE) cohort. The main outcome was QOL (Pediatric QOL Inventory [PedsQL]). Biological covariates included age, sex, body mass index z score, glycated hemoglobin, estimated glomerular filtration rate, and urine albumin-to-creatinine ratio. Psychological factors included perceived stress (14-item Perceived Stress Scale) and mental distress (6-item Kessler scale). Social factors included food security (Household Food Security Survey Module) and income quintile. Multivariate linear regression analyses were used to identify factors associated with QOL between adolescents with and without T2D, and within the T2D cohort. RESULTS: Mean total QOL scores among adolescents with T2D were lower than in controls (67.0±14.8 vs 71.7±16.2, p=0.04). Age, sex, and percent Indigenous ethnicity were not significantly different between groups. Mean duration of T2D was 2.3±2.0 years. In the multivariate analysis, QOL was not associated with diabetes status, but negative associations were seen between mental distress (ß=-1.46, p<0.001) and food insecurity QOL (ß=-6.26, p=0.037). No differences were seen between biological factors and QOL in either analysis. CONCLUSIONS: Significant factors associated with decreased QOL in adolescents living with T2D include mental distress and food insecurity, indicating areas for targeted intervention.

Long-term Survival Among Patients With De Novo Human Epidermal Growth Receptor 2-Positive Metastatic Breast Cancer in Manitoba.

OBJECTIVES: Although metastatic breast cancer (MBC) is considered incurable, human epidermal growth receptor 2 (HER2)-directed therapy has improved outcomes significantly, with some patients experiencing durable responses to treatment. The aim of this study was to identify potential predictors of long-term survival (LTS) among patients with de novo HER2-positive MBC who received HER2-directed treatment. METHODS: Eligible patients from 2008 to 2018 were identified using the Manitoba Cancer Registry. LTS was defined as survival ≥5 years from the time of diagnosis. Univariate logistic regression models were performed to assess variables of clinical interest and the odds of LTS. Overall survival (OS) was defined as the time from diagnosis of MBC to death of any cause. OS was estimated using the Kaplan-Meier method with log-rank comparative analyses as a univariate analysis. A Cox proportional hazards model was used for OS estimates in a univariate analysis. RESULTS: A total of 62 patients were diagnosed with de novo HER2-positive MBC and received HER2-directed therapy. Eighteen (29%) achieved LTS. The median OS of the whole cohort was 50.2 months (95% CI: 28.6-not reached). Radiographic response to first-line treatment was associated with LTS; complete and partial responses were both associated with higher odds of LTS (odds ratio: 28.33 [95% CI: 2.47-4006.71, P = 0.0043] and odds ratio: 7.80 [95% CI: 0.7317-1072.00, P = 0.0972], respectively). The best radiographic response was associated with improved OS. CONCLUSIONS: Radiographic response to first-line HER2-directed therapy is a predictor for LTS in patients with de novo HER2-positive MBC. Larger studies are needed to identify patients who can safely discontinue HER2-targeted therapy.

Characterizing intubation practices in response to the COVID-19 pandemic: a survey of the Canadian COVID-19 Emergency Department Rapid Response Network (CCEDRRN) sites.

OBJECTIVE: The risk of occupational exposure during endotracheal intubation has required the global Emergency Medicine (EM), Anesthesia, and Critical Care communities to institute new COVID- protected intubation guidelines, checklists, and protocols. This survey aimed to deepen the understanding of the changes in intubation practices across Canada by evaluating the pre-COVID-19, early-COVID-19, and present-day periods, elucidating facilitators and barriers to implementation, and understanding provider impressions of the effectiveness and safety of the changes made. METHODS: We conducted an electronic, self-administered, cross-sectional survey of EM physician site leads within the Canadian COVID-19 Emergency Department Rapid Response Network (CCEDRRN) to characterize and compare airway management practices in the pre-COVID-19, early-COVID-19, and present-day periods. Ethics approval for this study was obtained from the University of Manitoba Health Research Ethics Board. The electronic platform SurveyMonkey ( www.surveymonkey.com ) was used to collect and store survey tool responses. Categorical item responses, including the primary outcome, are reported as numbers and proportions. Variations in intubation practices over time were evaluated through mixed-effects logistic regression models. RESULTS: Invitations were sent to 33 emergency department (ED) physician site leads in the CCEDRRN. We collected 27 survey responses, 4 were excluded, and 23 analysed. Responses were collected in English (87%) and French (13%), from across Canada and included mainly physicians practicing in mainly Academic and tertiary sites (83%). All respondents reported that the intubation protocols used in their EDs changed in response to the COVID-19 pandemic (100%, n = 23, 95% CI 0.86-1.00). CONCLUSIONS: This study provides a novel summary of changes to airway management practices in response to the evolving COVID-19 pandemic in Canada. Information from this study could help inform a consensus on safe and effective emergent intubation of persons with communicable respiratory infections in the future.

24-h ambulatory blood pressure readings and associations with albuminuria in youth with type 2 diabetes: A cross sectional analysis from the iCARE cohort.

AIMS: To evaluate associations between 24-h ambulatory blood pressure monitor (ABPM) data vs. single casual blood pressure (BP) and albuminuria in youth with type 2 diabetes. METHODS: A cross-sectional analysis of youth with type 2 diabetes 10-<18 yrs. from the iCARE cohort. MAIN EXPOSURES: daytime HTN (+/- nocturnal), isolated nocturnal HTN and single casual BP. MAIN OUTCOME: non-orthostatic urine albumin: creatinine ratio (ACR) ≥ 3 mg/mmol and log-transformed urine ACR. Regressions evaluated associations between 1. HTN status based on ABPM and log-transformed urine ACR (continuous) and 2. ABPM-derived BP z-scores and casual BPcentiles and albuminuria status (categorical). RESULTS: Of 281 youth included, 19.6 % had daytime HTN (+/- nocturnal), and 28.5 % isolated nocturnal HTN on 24-h ABPM. In multivariate linear regression, HTN (ABPM) (ß = 0.553; p = 0.001), duration of diabetes (ß = 0.857; p = 0.02), HbA1c (ß = 1.172; p ≤0.0001) and ACEI/ARB use (ß = 3.94; p < 0.0001) were positively associated with log-transformed ACR; (R2 = 0.184). In logistic regression analysis, all ABPM LMS z-scores were positively associated with albuminuria; casual BPcentile was not significant. CONCLUSIONS: Youth with type 2 diabetes have high rates of HTN based on 24-ABPM data. ABPM-derived measures of BP are associated with albuminuria. These data support the routine use of ABPM devices to diagnose hypertension in youth with type 2 diabetes.

A longitudinal study of distress symptoms and work impairment in immune-mediated inflammatory diseases.

OBJECTIVE: We investigated the association between distress symptoms (pain, fatigue, depression, anxiety) and work impairment in four patient populations: multiple sclerosis (N = 107), rheumatoid arthritis (N = 40), inflammatory bowel disease (N = 136) and psychiatric disorders (N = 167). METHODS: Four waves of data collection were completed over three years. The relationship between distress symptoms and overall work impairment was evaluated with univariate and multivariable quantile logistic regression at the 25th, 50th and 75th percentiles. Models were fit to participant average scores and change scores on distress symptom measures. Covariates included sociodemographic factors, comorbidity, physical disability and cognitive function. RESULTS: In the primary univariate analyses of overall work impairment at the 50th percentile, greater severity of distress symptoms was associated with greater work impairment: pain (average ß = 0.27, p < 0.001; change ß = 0.08, p < 0.001), fatigue (average ß = 0.21, p < 0.001; change ß = 0.09, p < 0.001) depression (average, ß = 0.35, p < 0.001; change, ß = 0.16, p < 0.001), anxiety (average, ß = 0.24, p < 0.001; change, ß = 0.08, p < 0 0.01). Findings were similar in multivariable analyses. CONCLUSION: Pain, fatigue, depression, and anxiety symptoms are important determinants of work impairment in persons with immune-mediated diseases and persons with psychiatric disorders. Successful clinical management of these symptoms has potential to improve work-related outcomes across IMIDs.

Intersectional characterization of emergency department (ED) staff experiences of racism: a survey of ED healthcare workers for the Disrupting Racism in Emergency Medicine (DRiEM) Investigators.

INTRODUCTION: The impact of racism on patient outcomes in Emergency Medicine has been examined but there have been few studies exploring the experiences of racism in health care workers. This survey aims to explore the experience of racism by interdisciplinary staff in a tertiary ED. By characterizing the staff experience of racism in the ED, we hope to inform the design of strategies to disrupt racism and ultimately improve the health and wellness of both staff and patients. METHODS: We conducted a self-administered, cross-sectional survey to explore the reported experience of racism by healthcare workers in a single urban ED in an academic trauma centre. We employed classification and regression tree analyses to evaluate predictors of racism through an intersectional lens. RESULTS: A majority (n = 200, 75%) of all ED staff reported experiencing interpersonal racism (including physical violence, direct verbal violence, mistreatment and/or microaggressions) in the workplace. Respondents who identified as racialized self-reported significantly more racism at work than white respondents (86% vs. 63%, p < 0.001). Occupation, race, migrant status and age were identified through intersectional machine-learning models to be significantly predictive of the experience of racism. Nearly all respondents felt that the disruption of racism in Emergency medicine is important to them (90%, n = 207) and (93%, n = 214) were willing to participate in further training in anti-racism. CONCLUSIONS: Racism against interdisciplinary staff working in EDs is common and the burden on healthcare workers is high. Intersections of occupation, race, age and migrant status are uniquely predictive of the experience of racism for EM staff. Interventions to disrupt racism should be informed by intersectional considerations to create a safe working environment and target populations most at risk. ED healthcare workers are willing to take steps to disrupt racism in their workplace and need institutional support to do so.

ABSTRAIT: INTRODUCTION: L'impact du racisme sur les résultats des patients en médecine d'urgence a été examiné, mais peu d'études ont exploré les expériences de racisme chez les travailleurs de la santé. Cette enquête vise à explorer l'expérience du racisme par le personnel interdisciplinaire dans un ED tertiaire. En caractérisant l'expérience de racisme du personnel à l'urgence, nous espérons éclairer la conception de stratégies visant à perturber le racisme et, ultimement, à améliorer la santé et le bien-être du personnel et des patients. MéTHODES: Nous avons mené une enquête transversale auto-administrée pour explorer l'expérience signalée de racisme par les travailleurs de la santé dans un seul service d'urgence urbain dans un centre de traumatologie universitaire. Nous avons utilisé des analyses d'arbres de classification et de régression pour évaluer les prédicteurs du racisme dans une optique intersectionnelle. RéSULTATS: La majorité (n = 200, 75 %) de tous les employés de l'urgence ont déclaré avoir été victimes de racisme interpersonnel (y compris de violence physique, de violence verbale directe, de mauvais traitements ou de microagressions) en milieu de travail. Les répondants qui se sont identifiés comme racialisés ont déclaré beaucoup plus de racisme au travail que les répondants blancs (86 % c. 63 %, p < 0,001). La profession, la race, le statut de migrant et l'âge ont été identifiés par des modèles d'apprentissage automatique intersectionnels pour être significativement prédictifs de l'expérience du racisme. Presque tous les répondants étaient d'avis que la perturbation du racisme en médecine d'urgence était importante pour eux (90 %, n = 207) et (93 %, n = 214) étaient disposés à suivre une formation plus poussée en matière de lutte contre le racisme. CONCLUSIONS: Le racisme à l'égard du personnel interdisciplinaire travaillant dans les DEA est courant et le fardeau imposé aux travailleurs de la santé est élevé. Les intersections de la profession, de la race, de l'âge et du statut de migrant sont des prédictions uniques de l'expérience du racisme pour le personnel EM. Les interventions visant à perturber le racisme devraient être fondées sur des considérations intersectionnelles afin de créer un environnement de travail sécuritaire et de cibler les populations les plus à risque. Les travailleurs de la santé ED sont prêts à prendre des mesures pour perturber le racisme dans leur milieu de travail et ont besoin du soutien institutionnel pour le faire.

Postoperative neurological symptoms following arthroscopic shoulder surgery with interscalene block: an exploratory secondary analysis of pooled randomized controlled trial data.

OBJECTIVE: Postoperative neurological symptoms (PONS) are recognized complications of regional anesthesia and orthopedic surgery. We aimed to better characterize prevalence and potential risk factors in a homogeneous population of randomized, controlled trial participants. METHODS: Data were pooled from two randomized controlled trials of analgesia after interscalene block with perineural or intravenous adjuvants (NCT02426736, NCT03270033). Participants were at least 18 years of age and undergoing arthroscopic shoulder surgery at a single ambulatory surgical center. PONS were assessed by telephone follow-up at 14 days and 6 months postoperatively, and defined as patient report of numbness, weakness, or tingling in the surgical limb, alone or in combination, and regardless of severity or etiology. RESULTS: At 14 days, PONS occurred in 83 of 477 patients (17.4%). Among these 83 patients, 10 (12.0%) continued to have symptoms a half-year after surgery. In exploratory univariate analyses, no patient, surgical or anesthetic characteristics were significantly associated with 14-day PONS except for lower postoperative day 1 Quality of Recovery-15 questionnaire total score (OR 0.97 (95% CI, 0.96 to 0.99), p<0.01). This result was driven largely by the emotional domain question scores (OR 0.90 95% CI 0.85 to 0.96, p<0.001). Report of all three of numbness, weakness and tingling at 14 days vs other 14-day symptom combinations was associated with persistent PONS at 6 months (OR 11.5 95% CI 2.2 to 61.8, p<0.01). CONCLUSION: PONS are common after arthroscopic shoulder surgery performed with single injection ultrasound-guided interscalene blocks. No definitive mitigating risk factors were identified.

Emergency airway management in a tertiary trauma centre (AIRMAN): a one-year prospective longitudinal study.

PURPOSE: Emergency airway management can be associated with a range of complications including long-term neurologic injury and death. We studied the first-pass success rate with emergency airway management in a tertiary care trauma centre. Secondary outcomes were to identify factors associated with first-pass success and factors associated with adverse events peri-intubation. METHODS: We performed a single-centre, prospective, observational study of patients ≥ 17 yr old who were intubated in the emergency department (ED), surgical intensive care unit (SICU), medical intensive care unit (MICU), and inpatient wards at our institution. Ethics approval was obtained from the local research ethics board. RESULTS: In a seven-month period, there were 416 emergency intubations and a first-pass success rate of 73.1%. The first-pass success rates were 57.5% on the ward, 66.1% in the intensive care units (ICUs) and 84.3% in the ED. Equipment also varied by location; videolaryngoscopy use was 65.1% in the ED and only 10.6% on wards. A multivariate regression model using the least absolute shrinkage and selection algorithm (LASSO) showed that the odds ratios for factors associated with two or more intubation attempts were location (wards, 1.23; MICU, 1.24; SICU, 1.19; reference group, ED), physiologic instability (1.19), an anatomically difficult airway (1.05), hypoxemia (1.98), lack of neuromuscular blocker use (2.28), and intubator inexperience (1.41). CONCLUSIONS: First-pass success rates varied widely between locations within the hospital and were less than those published from similar institutions, except for the ED. We are revamping ICU protocols to improve the first-pass success rate.

RéSUMé: OBJECTIF: La prise en charge d'urgence des voies aériennes peut être associée à une multitude de complications, y compris des lésions neurologiques à long terme et la mort. Nous avons étudié le taux de réussite à la première tentative lors de la prise en charge d'urgence des voies aériennes dans un centre de traumatologie tertiaire. Les critères d'évaluation secondaires étaient l'identification des facteurs associés à la réussite de la première tentative et des facteurs associés aux événements indésirables péri-intubation. MéTHODE: Nous avons réalisé une étude observationnelle prospective monocentrique sur des patients âgés de 17 ans ou plus qui avaient été intubés à l'urgence, à l'unité de soins intensifs chirurgicaux (USIC), à l'unité de soins intensifs médicaux (USIM) et aux étages dans notre établissement. L'approbation a été obtenue du comité d'éthique de la recherche local. RéSULTATS: Au cours d'une période de sept mois, il y a eu 416 intubations d'urgence et un taux de réussite à la première tentative de 73,1 %. Les taux de réussite à la première tentative étaient de 57,5 % aux étages, de 66,1 % dans les unités de soins intensifs (USI) et de 84,3 % à l'urgence. Le matériel variait également selon l'emplacement; l'utilisation de la vidéolaryngoscopie était de 65,1 % à l'urgence et de seulement 10,6 % aux étages. Un modèle de régression multivariée utilisant l'algorithme LASSO (Least Absolute Shrinkage and Selection Algorithm) a montré que les rapports de cotes pour les facteurs associés à deux tentatives d'intubation ou plus étaient l'emplacement (étages, 1,23; USIM, 1,24; USIC, 1,19; groupe de référence, urgence), l'instabilité physiologique (1,19), des voies aériennes présentant des complications anatomiques (1,05), l'hypoxémie (1,98), la non-utilisation de bloqueurs neuromusculaires (2,28) et l'inexpérience de la personne pratiquant l'intubation (1,41). CONCLUSION: Les taux de réussite à la première tentative variaient considérablement d'un emplacement à l'autre au sein de l'hôpital et étaient inférieurs à ceux publiés par des établissements comparables, à l'exception du service des urgences. Nous retravaillons les protocoles des soins intensifs afin d'améliorer le taux de réussite à la première tentative.

A prospective observational study comparing outcomes before and after the introduction of an intubation protocol during the COVID-19 pandemic.

OBJECTIVE: Orotracheal intubation is a life-saving procedure commonly performed in the Intensive Care unit and Emergency Department as a part of emergency airway management. Prior to the COVID-19 pandemic, our center undertook a prospective observational study to characterize emergency intubation performed in the emergency department and critical care settings at Manitoba's largest tertiary hospital. During this study, a natural experiment emerged when a standardized "COVID-Protected Rapid Sequence Intubation Protocol" was implemented in response to the pandemic. The resultant study aimed to answer the question; in adult ED patients undergoing emergent intubation by EM and CCM teams, does the use of a "COVID-Protected Rapid Sequence Intubation Protocol" impact first-pass success or other intubation-related outcomes? METHODS: A single-center prospective quasi-experimental before and after study was conducted. Data were prospectively collected on consecutive emergent intubations. The primary outcome was the difference in first-pass success rates. Secondary outcomes included best Modified Cormack-Lehane view, hypoxemia, hypotension, esophageal intubation, cannot intubate cannot oxygenate scenarios, CPR post intubation, vasopressors required post intubation, Intensive Care Unit (ICU) mortality, ICU length of stay (LOS), and mechanical ventilation days. RESULTS: Data were collected on 630 patients, 416 in the pre-protocol period and 214 in the post-protocol period. First-pass success rates in the pre-protocol period were found to be 73.1% (n = 304). Following the introduction of the protocol, first-pass success rates increased to 82.2% (n = 176, p = 0.0105). There was a statistically significant difference in Modified Cormack-Lehane view favoring the protocol (p = 0.0191). Esophageal intubation rates were found to be 5.1% pre-protocol introduction versus 0.5% following the introduction of the protocol (p = 0.0172). CONCLUSION: A "COVID-Protected Protocol" implemented by Emergency Medicine and Critical Care teams in response to the COVID-19 pandemic was associated with increased first-pass success rates and decreases in adverse events.

RéSUMé: OBJECTIFS: L'intubation orotrachéale est une procédure de sauvetage couramment réalisée dans l'unité de soins intensifs et le service des urgences dans le cadre de la gestion des voies aériennes d'urgence. Avant la pandémie de COVID-19, notre centre a entrepris une étude prospective d'observation pour caractériser l'intubation d'urgence effectuée dans le service des urgences et les établissements de soins intensifs du plus grand hôpital tertiaire du Manitoba. Au cours de cette étude, une expérience naturelle est apparue lorsqu'un " protocole d'intubation à séquence rapide protégé contre le COVID " standardisé a été mis en œuvre en réponse à la pandémie. L'étude qui en a résulté visait à répondre à la question suivante : chez les patients adultes des urgences soumis à une intubation urgente par les équipes de médecine d'urgence et de médecine de soins critiques, l'utilisation d'un " protocole d'intubation à séquence rapide protégé par COVID " a-t-elle un impact sur la réussite du premier passage ou sur d'autres résultats liés à l'intubation ? MéTHODE: Une étude prospective quasi-expérimentale avant et après a été menée dans un seul centre. Les données ont été recueillies prospectivement sur des intubations émergentes consécutives. Le résultat principal était la différence entre les taux de réussite au premier passage. Les résultats secondaires comprenaient la meilleure vue de Cormack­Lehane modifiée, l'hypoxémie, l'hypotension, l'intubation œsophagienne, les scénarios d'impossibilité d'intubation et d'oxygénation, la réanimation cardio-pulmonaire après l'intubation, les vasopresseurs nécessaires après l'intubation, la mortalité en unité de soins intensifs (USI), la durée de séjour en USI et les jours de ventilation mécanique. RéSULTATS: Des données ont été recueillies sur 630 patients, 416 dans la période pré-protocole et 214 dans la période post-protocole. Les taux de réussite au premier passage dans la période pré-protocole se sont avérés être de 73,1 % (n = 304). Suite à l'introduction du protocole, les taux de réussite au premier passage ont augmenté à 82,2 % (n = 176, p = 0,0105). Il y avait une différence statistiquement significative dans la vue Cormack­Lehane modifiée en faveur du protocole (p = 0,0191). Les taux d'intubation œsophagienne se sont avérés être de 5,1 % avant l'introduction du protocole contre 0,5 % après l'introduction du protocole (p = 0,0172). CONCLUSION: Un « protocole protégé contre la COVID ¼ mis en œuvre par les équipes de médecine d'urgence et de médecine de soins critiques en réponse à la pandémie de COVID-19 a été associé à une augmentation des taux de réussite du premier passage et à une diminution des événements indésirables.

The Relationship Between Body Mass Index and the Magnitude of Curve at Diagnosis of Adolescent Idiopathic Scoliosis: A Retrospective Chart Review.

Purpose: To evaluate the relationship between body mass index (BMI) and spinal curvature in patients presenting with idiopathic scoliosis at a major pediatric tertiary care centre. Patients and Methods: Retrospective chart review (2015-2019). Data extracted from patient's first visit included age, sex, height, weight, spinal curvature (magnitude, location), referral source, physical activity participation (yes/no), pain (yes/no). Demographics were analyzed descriptively. The relationship between BMI and spinal curve magnitude was analyzed using Spearman correlation coefficient. Linear regression was applied to determine the relationship between BMI, curve magnitude, and curve location. Exploratory univariate analyses were conducted for BMI and referral source, pain, and skeletal maturity, and physical activity and pain. Results: A total of 206 patient charts were included (177 females, 29 males). Patients presented with double major (41.3%), thoracic (26.7%), thoracolumbar (22.8%), and lumbar (9.2%) curves. Mean (SD) BMI percentile was 48.3 (30.5). No relationship existed between BMI percentile and curve magnitude with curve locations combined. However, a test for interaction revealed a positive relationship between BMI percentile and curve magnitude for adolescents with double major curves, and a negative relationship for adolescents with thoracic curves. Exploratory analyses suggested a relationship between BMI percentile and presence of pain, and between referral source and curve magnitude. No relationship was observed between BMI and skeletal maturity, or physical activity and pain. Conclusion: The relationship between BMI varied by curve location within this cohort, in which most patients presented with a BMI <85th percentile. Findings highlight the importance of sensitive history taking and careful physical examination for early detection of scoliosis.

Chronic kidney damage pathology score for systematic assessment of the non-neoplastic kidney tissue and prediction of post-operative renal function outcomes.

To establish a systematic histological assessment of non-neoplastic kidney (NNK) tissue at the time of nephrectomy to evaluate a patient's risk of developing post-operative renal dysfunction, a combined prospective pathologic assessment of the NNK and a retrospective clinical chart review was conducted. A blinded nephropathologist performed standardized assessment of glomerular sclerosis, tubulointerstitial fibrosis, arteriosclerosis, and hyaline arteriolosclerosis. Combined these formulated the chronic kidney damage pathology score (CKDPS). Multivariate logistic regression models were developed to assess the effect of CKDPS and other clinical factors on renal function up to 24 months following nephrectomy (partial or radical). 156 patients were included in the analysis with a median age of 60 years. 70% patients underwent radical nephrectomy. A history of hypertension and/or diabetes was present in 55.8% and 22.1%, respectively. Higher CKDPS (particularly glomerular global sclerosis and arteriosclerosis scores), radical nephrectomy, and reduced baseline estimated glomerular filtration rate (eGFR) were associated with worsening post-operative renal function outcomes. The systematic assessment of non-neoplastic kidney tissue at the time of renal surgery can help identify patients at risk of post-operative renal dysfunction. CKDPS represents a standardized and prognostically relevant histologic reporting system for non-neoplastic kidney tissue.

Maternal body mass index, offspring body mass index, and blood pressure at 18 years: a causal mediation analysis.

OBJECTIVE: Understanding the natural history of hypertension is key to identifying prevention strategies. Previous work suggests that in utero exposures and offspring anthropometrics may play a role. This study examined the relationship between maternal pre-pregnancy body mass index (BMI) and the mediating role of childhood and adolescent BMI on offspring blood pressure at 18 years. METHODS: We performed multivariable regression and causal mediation analyses within 3217 mother - offspring pairs from the Avon Longitudinal Study of Parents and Children prospective birth cohort. The main exposure was maternal pre-pregnancy BMI, and the outcome was offspring blood pressure at 18 years of age categorized as normal or elevated. Latent trajectory analysis was used to quantify the mediator, offspring BMI trajectories, derived from multiple measurements throughout childhood and adolescence. Mediation analyses were repeated using current offspring BMI at 18 years as a continuous variable. RESULTS: Multivariable logistic regression revealed that for every 1 unit increase in maternal BMI, the risk of elevated blood pressure at 18 years of age increased by 5% (aOR: 1.05, 95% CI: 1.03-1.07; p < 0.001). The strength of this association was reduced after adjusting for offspring BMI trajectory (aOR: 1.03, 95% CI: 1.00-1.05; p = 0.017) and eliminated after adjusting for offspring BMI at 18 years (aOR: 1.00; 95% CI: 0.98-1.03; p = 0.70). Causal mediation analysis confirmed offspring BMI at 18 years as a mediator, where BMI trajectory accounted for 46% of the total effect of maternal BMI on elevated offspring blood pressure and current BMI account for nearly the entire effect. CONCLUSIONS: Maternal pre-pregnancy BMI is associated with an increased risk of elevated blood pressure in offspring at 18 years of age although it appears to be entirely mediated by offspring BMI.

Analgesic duration of interscalene block after outpatient arthroscopic shoulder surgery with intravenous dexamethasone, intravenous dexmedetomidine, or their combination: a randomized-controlled trial.

PURPOSE: Both intravenous dexamethasone and dexmedetomidine prolong the analgesic duration of interscalene blocks (ISB) after arthroscopic shoulder surgery. This study compared their relative effectiveness and the benefit of their use in combination. METHODS: This single-centre, double-blinded, parallel three-group superiority trial randomized 198 adult patients undergoing ambulatory arthroscopic shoulder surgery. Patients received preoperative ISB with 30 mL 0.5% bupivacaine and 50 µg dexmedetomidine or 4 mg dexamethasone or both of these agents as intravenous adjuncts. The primary outcome was analgesic block duration. Secondary outcomes included the quality of recovery 15 score (range: 0-150) on day 1 and postoperative neurologic symptoms in the surgical arm. RESULTS: Block durations (n = 195) with dexamethasone (median [range], 24.5 [2.0-339.5] hr) and both adjuncts (24.0 [1.5-157.0] hr) were prolonged compared with dexmedetomidine (16.0 [1.5-154.0] hr). When analyzed by linear regression after an unplanned log transformation because of right-skewed data, the corresponding prolongations of block duration were 59% (95% confidence interval [CI], 28 to 97) and 46% (95% CI, 18 to 80), respectively (both P < 0.001). The combined adjuncts were not superior to dexamethasone alone (-8%; 95% CI, -26 to 14; P = 0.42). Median [IQR] quality of recovery 15 scores (n = 197) were significantly different only between dexamethasone (126 [79-149]) and dexmedetomidine (118.5 [41-150], P = 0.004), but by an amount less than the 8-point minimum clinically important difference. CONCLUSION: Dexamethasone is superior to dexmedetomidine as an intravenous adjunct for prolongation of bupivacaine-based ISB analgesic duration. There was no additional benefit to using both adjuncts in combination. TRIAL REGISTRATION: www.clinicaltrials.gov (NCT03270033); registered 1 September 2017.

RéSUMé: OBJECTIF: La dexaméthasone et la dexmédétomidine intraveineuses prolongent toutes deux la durée analgésique des blocs interscaléniques (BIS) après une chirurgie arthroscopique de l'épaule. Cette étude a comparé leur efficacité relative et les avantages d'une utilisation des deux agents en combinaison. MéTHODE: Cette étude de supériorité monocentrique en trois groupes parallèles à double insu a randomisé 198 patients adultes subissant une chirurgie arthroscopique de l'épaule en ambulatoire. Les patients ont reçu un BIS préopératoire composé de 30 mL de bupivacaïne 0,5 % avec 50 µg de dexmédétomidine, 4 mg de dexaméthasone, ou la combinaison de ces deux agents comme adjuvants intraveineux. Le critère d'évaluation principal était la durée analgésique du bloc. Les critères d'évaluation secondaires comprenaient le score de qualité de récupération (QoR) 15 (plage : 0-150) au jour 1 et les symptômes neurologiques postopératoires dans le bras opéré. RéSULTATS: Les durées des blocs (n = 195) avec la dexaméthasone (médiane [plage], 24,5 [2,0-339,5] heures) et la combinaison des deux adjuvants (24,0 [1,5-157,0] heures) ont été prolongées par rapport à la dexmédétomidine (16,0 [1,5-154,0] heures). Lorsqu'elles ont été analysées par régression linéaire après une transformation logarithmique non planifiée en raison de données biaisées vers la droite, les prolongations correspondantes de la durée du bloc étaient de 59 % (intervalle de confiance [IC] 95 %, 28 à 97) et de 46 % (IC 95 %, 18 à 80), respectivement (les deux P < 0,001). La combinaison des adjuvants n'était pas supérieure à la dexaméthasone seule (-8 %; IC 95 %, -26 à 14; P = 0,42). Les scores médians [ÉIQ] de qualité de récupération 15 (n = 197) n'étaient significativement différents qu'entre la dexaméthasone (126 [79-149]) et la dexmédétomidine (118,5 [41-150], P = 0,004), mais la différence observée était inférieure à la différence minimale de 8 points nécessaire pour être considérée cliniquement importante. CONCLUSION: La dexaméthasone est supérieure à la dexmédétomidine en tant qu'adjuvant intraveineux pour prolonger la durée analgésique d'un BIS à base de bupivacaïne. Aucun avantage supplémentaire n'a été observé lors de l'utilisation combinée des deux adjuvants. ENREGISTREMENT DE L'éTUDE: www.clinicaltrials.gov (NCT03270033); enregistrée le 1er septembre 2017.

The Epidemiology of Endocarditis in Manitoba: A Retrospective Study.

BACKGROUND: Recently, anecdotal evidence suggested an increase in infective endocarditis (IE) in Manitoba driven by an increasing proportion of patients with intravenous drug use (IVDU)-associated endocarditis. This study aimed to characterize the observed changing incidence and epidemiology of IE. METHODS: This retrospective study evaluated consecutive patients >18 years old with an International Classification of Disease-10 diagnosis of IE who presented to a tertiary referral center in Winnipeg, Manitoba between January 1, 2004 and December 31, 2018. Data were obtained by individual review of paper and electronic medical records and entered into the Research Electronic Data Capture database. Mortality and hospital readmission data were acquired by linking Research Electronic Data Capture data to the Manitoba Centre for Health Policy, which prospectively maintains a comprehensive population-based health database. RESULTS: A total of 612 cases of IE were identified. The incidence of IE increased from 2.03 per 100,000 in 2004 to 5.16 per 100,000 in 2018, with IVDU-associated cases increasing from 0.11 to 2.87 per 100,000. Left heart vegetations were most common in the non-IVDU group, whereas right-sided vegetations dominated in the IVDU group. All-cause mortality did not differ between IVDU and non-IVDU IE, despite a significantly younger age in patients with IVDU. The IVDU group showed a higher rate of endocarditis recurrence. CONCLUSIONS: In this first study to examine the longitudinal incidence of IE in Manitoba, we showed that the incidence of IE has significantly increased over the last 15 years, with a contribution of IVDU-associated IE that has a high rate of mortality and disease recurrence.

INTRODUCTION: Des données anecdotiques récentes montraient une augmentation de l'endocardite infectieuse (EI) au Manitoba attribuable à la proportion accrue de patients atteints d'une endocardite associée à l'usage de drogues par voie intraveineuse (UDVI). La présente étude avait pour but de caractériser les changements observés dans l'incidence et l'épidémiologie de l'EI. MÉTHODES: Cette étude rétrospective a permis d'évaluer les patients consécutifs > 18 ans qui avaient un diagnostic d'EI conformément à la Classification internationale des maladies, 10e révision, et qui s'étaient présentés dans un centre d'aiguillage en soins tertiaires de Winnipeg, au Manitoba, entre le 1er janvier 2004 et le 31 décembre 2018. Nous avons obtenu les données par l'examen du dossier individuel et des dossiers médicaux électroniques de la base de données Research Electronic Data Capture. Nous avons obtenu les données sur la mortalité et les réadmissions à l'hôpital par la liaison des données de la Research Electronic Data Capture au Manitoba Centre for Health Policy, qui maintient de manière prospective une base de données exhaustive sur la santé de la population. RÉSULTATS: Nous avons trouvé un total de 612 cas d'EI. L'incidence de l'EI est passée de 2,03 par 100 000 en 2004 à 5,16 par 100 000 en 2018, et l'incidence des cas d'EI associée à l'UDVI, de 0,11 à 2,87 par 100 000. Les végétations du cœur gauche étaient plus fréquentes dans le groupe de patients atteints d'une EI non associée à l'UDVI, alors que les végétations du cœur droit dominaient dans le groupe de patients atteints d'une EI associée à l'UDVI. La mortalité toutes causes confondues ne différait pas entre les patients atteints d'une EI associée à l'UDVI ou non associée à l'UDVI, en dépit de l'âge significativement plus jeune des patients atteints d'une EI associée à l'UDVI. Le groupe de patients atteints d'une EI associée à l'UDVI montrait un taux plus élevé de récurrence de l'endocardite. CONCLUSIONS: Dans cette première étude, qui portait sur l'incidence longitudinale de l'EI au Manitoba, nous avons montré que l'incidence de l'EI avait considérablement augmenté au cours des 15 dernières années, puisque l'EI associée à l'UDVI a contribué à l'augmentation du taux de mortalité et de récurrence de la maladie.

Developing a crosswalk between the RAND-12 and the health utilities index for multiple sclerosis.

BACKGROUND: Researchers studying health-related quality of life (HRQOL) in multiple sclerosis (MS) can choose from many instruments, but findings from studies which use different instruments cannot be easily combined. We aimed to develop a crosswalk that associates scores from the RAND-12 to scores on the Health Utilities Index-Mark III (HUI3) in persons with MS. METHODS: In 2018, participants in the North American Research Committee on Multiple Sclerosis (NARCOMS) registry completed the RAND-12 and the HUI3 to assess HRQOL. We used item-response theory (IRT) and equipercentile linking approaches to develop a crosswalk between instruments. We compared predicted scores for the HUI3 from each crosswalk to observed scores using Pearson correlations, intraclass correlation coefficients (ICCs), and Bland-Altman plots. RESULTS: Of 11,389 invited participants, 7129 (62.6%) responded. Predicted and observed values of the HUI3 from the IRT-linking method were moderately correlated (Pearson r = 0.76) with good concordance (ICC = 0.72). However, the Bland-Altman plots suggested biased prediction. Predicted and observed values from the equipercentile linking method were also moderately correlated (Pearson r = 0.78, ICC = 0.78). The Bland-Altman plots suggested no bias. CONCLUSION: We developed a crosswalk between the RAND-12 and the HUI3 in the MS population which will facilitate data harmonization efforts.

Examining the cross-sectional and longitudinal effects of anxiety sensitivity on indicators of disease severity among patients with inflammatory arthritis.

Few studies have investigated anxiety sensitivity (AS) in the context of inflammatory arthritis (IA), despite evidence of a relationship between AS and pain. This study examined cross-sectional and longitudinal relationships between AS and indicators of IA severity in 148 participants with IA. AS and its factors (social, physical, cognitive) were self-reported. Arthritis severity was physician-assessed (disease activity scales) and self-reported (physical function; pain and fatigue). Cross-sectional correlations assessed the association between AS and arthritis severity outcomes. Longitudinal multivariable mixed-effect regressions assessed the association of AS total and AS factors at each visit with disease severity outcomes. All AS factors were significantly and positively correlated (at the same visit) with function, pain, and fatigue. AS total significantly predicted pain, fatigue, and function. Cognitive AS significantly predicted fatigue, and physical AS significantly predicted pain and fatigue. Social AS significantly predicted pain, fatigue, function and weighted joint count (articular burden). AS is associated with several indicators of disease severity among those with IA; unique findings emerged across factors with the broadest disease impact by social AS. The AS factors, especially social AS, may contribute to the development and severity of IA symptoms, which may have implications for interventions.