Non-suicidal self-injury at a Canadian paediatric emergency department.

OBJECTIVE: Our primary objective was to determine agreement between non-suicidal self-injury recorded at triage and during subsequent mental health assessment. The secondary objective was to describe patients who reported non-suicidal self-injury. METHODS: This is a health records review of patients aged 12-18 years who had an Emergency Mental Health Triage form on their health record from an ED visit June 1, 2017-May 31, 2018. We excluded patients with diagnoses of autism spectrum disorder or schizophrenia. We abstracted data from the Mental Health Triage form, Emergency Mental Health and Addictions Service Assessment forms and Assessment of Suicide and Risk Inventory. We calculated Cohen's Kappa coefficient, sensitivity, and negative predictive value to describe the extent to which the forms agreed and the performance of triage for identifying non-suicidal self-injury. We compared the cohort who reported non-suicidal self-injury with those who did not, using t-tests, Wilcoxon rank-sum tests, and chi-square tests. RESULTS: We screened 955 ED visits and included 914 ED visits where 558 (58.4%) reported a history of non-suicidal self-injury. There were significantly more females in the group reporting non-suicidal self-injury (82.1%, n = 458) compared to the group not reporting non-suicidal self-injury (45.8%, n = 163). Patients reporting non-suicidal self-injury did so in triage and detailed Mental Health Assessment 64.7% of the time (Cohen's Kappa Coefficient 0.6); triage had sensitivity of 71.5% (95% CI 67.3-75.4) and negative predictive value of 71.2% (95% CI 68.2-74.0). Cutting was the most common method of non-suicidal self-injury (80.3%). CONCLUSION: Screening at triage was moderately effective in identifying non-suicidal self-injury compared to a detailed assessment by a specialised mental health team. More than half of children and adolescents with a mental health-related concern in our ED reported a history of non-suicidal self-injury, most of which were female. This symptom is important for delineating patients' coping strategies.

RéSUMé: OBJECTIFS: Notre objectif principal était de déterminer l'accord entre les blessures non suicidaires enregistrées au triage et lors de l'évaluation subséquente de la santé mentale. L'objectif secondaire était de décrire les patients qui ont déclaré une automutilation non suicidaire. MéTHODES: Il s'agit d'un examen des dossiers de santé de patients âgés de 12 à 18 ans qui avaient un formulaire de triage d'urgence en santé mentale dans leur dossier de santé à la suite d'une visite à l'urgence du 1er juin 2017 au 31 mai 2018. Nous avons exclu les patients présentant un diagnostic de trouble du spectre autistique ou de schizophrénie. Nous avons extrait des données du formulaire de triage en santé mentale, des formulaires d'évaluation des services d'urgence en santé mentale et en toxicomanie et de l'évaluation du suicide et de l'inventaire des risques. Nous avons calculé le coefficient de Kappa de Cohen, la sensibilité et la valeur prédictive négative pour décrire la mesure dans laquelle les formes étaient d'accord et la performance du triage pour identifier l'automutilation non suicidaire. Nous avons comparé la cohorte qui a déclaré une automutilation non suicidaire avec celles qui ne l'ont pas fait, en utilisant des tests t-tests, des tests Wilcoxon rank-sum et des tests chi-carrés. RéSULTATS: Nous avons examiné 955 visites à l'urgence et inclus 914 visites à l'urgence où 558 (58,4 %) ont signalé des antécédents d'automutilation non suicidaire. Il y avait beaucoup plus de femmes dans le groupe déclarant une automutilation non suicidaire (82,1 %, n = 458) que dans le groupe ne déclarant pas une automutilation non suicidaire (45,8 %, n = 163). Les patients ayant déclaré une automutilation non suicidaire l'ont fait dans le cadre du triage et de l'évaluation détaillée de la santé mentale 64,7 % du temps (coefficient de Kappa de Cohen 0,6); le triage avait une sensibilité de 71,5 % (IC à 95 % 67,3­75,4) et une valeur prédictive négative de 71,2 % (IC à 95 % 68,2­74,0). La coupe était la méthode la plus courante d'automutilation non suicidaire (80,3 %). CONCLUSION: Le dépistage au triage a été modérément efficace pour identifier les blessures non suicidaires comparativement à une évaluation détaillée par une équipe spécialisée en santé mentale. Plus de la moitié des enfants et des adolescents ayant un problème de santé mentale à notre DE ont signalé des antécédents d'automutilation non suicidaire, dont la plupart étaient des femmes. Ce symptôme est important pour délimiter les stratégies d'adaptation des patients.

Perceptions of gender equity in emergency medicine in Canada.

INTRODUCTION: Women-identifying emergency physicians face gender-based discrimination throughout their careers. The purpose of this study was to explore emergency physician's perceptions and experiences of gender equity in emergency medicine. METHODS: We conducted a secondary analysis of data from a previously conducted survey of Canadian emergency physicians on barriers to gender equity in emergency medicine. Survey responses were analyzed using logistic regression to determine the impact that gender, practice setting, years since graduation, race, equity-seeking status, and parental status had on agreement about gender equity in emergency medicine and five of the problem statements. RESULTS: A total of 710 participants completed the survey. Most identified as women (58.8%), white (77.4%), graduated between 2010 and 2019 (40%), had CCFP (Emergency Medicine) designation (47.9%), an urban practice (84.4%), were parents (62.4%) and did not identify as equity-seeking (79.9%). Women-identifying physicians were less likely to perceive gender equity in emergency medicine, OR 0.52, CI [0.38, 0.73]. Women-identifying physicians were more likely to agree with statements about microaggressions, OR 4.39, CI [2.66, 7.23]; barriers to leadership, OR 3.51, CI [2.25, 5.50]; gender wage gap, OR 13.46, CI [8.27, 21.91]; lack of support for parental leave, OR 2.85, CI [1.82, 4.44]; and education on allyship, OR 2.23 CI [1.44, 3.45] than men-identifying physicians. CONCLUSION: In this study, women-identifying physicians were less likely to perceive that there was gender equity in emergency medicine than men-identifying physicians. Women-identifying physicians agreed that there are greater barriers for career advancement including fewer opportunities for leadership, a gender wage gap, a lack of parental leave policies to support a return to work and a lack of education for men to become allies. Men-identifying physicians were less aware of these inequities. Health systems must work to improve gender equity in emergency medicine and this will require education and allyship from men-identifying physicians.

RéSUMé: INTRODUCTION: Les femmes médecins urgentistes sont confrontées à une discrimination fondée sur le sexe tout au long de leur carrière. L'objectif de cette étude était d'explorer les perceptions et les expériences des médecins urgentistes en matière d'équité entre les sexes en médecine d'urgence. MéTHODES: Nous avons procédé à une analyse secondaire des données d'une enquête menée précédemment auprès des médecins urgentistes canadiens sur les obstacles à l'équité entre les sexes en médecine d'urgence. Les réponses au sondage ont été analysées à l'aide d'une régression logistique pour déterminer l'incidence que le sexe, le milieu de pratique, les années écoulées depuis l'obtention du diplôme, la race, le statut de demandeur d'équité et le statut parental avaient sur l'accord sur l'équité entre les sexes en médecine d'urgence et cinq des énoncés de problème. RéSULTATS: Au total, 710 participants ont répondu à l'enquête. La plupart d'entre eux sont des femmes (58.8 %), de race blanche (77.4 %), ont obtenu leur diplôme entre 2010 et 2019 (40 %), ont le titre de CCMF (médecine d'urgence) (47.9 %), exercent en milieu urbain (84.4 %), sont parents (62.4 %) et ne se déclarent pas en quête d'équité (79.9 %). Les médecins s'identifiant à des femmes étaient moins susceptibles de percevoir l'équité entre les sexes en médecine d'urgence, OR 0.52, IC [0.38,0.73]. Les médecins s'identifiant comme femmes étaient plus susceptibles d'être d'accord avec les déclarations sur les microagressions, OR 4.39, IC [2.66, 7.23] ; obstacles au leadership, OR 3.51, IC [2.25, 5.50] ; écart salarial entre les hommes et les femmes, OR 13.46, IC [8.27, 21.91] ; le manque de soutien pour le congé parental, OR 2.85, IC [1.82, 4.44]; et l'éducation sur l'alliance, OR 2.23 IC [1.44, 3.45] que les médecins s'identifiant comme hommes. CONCLUSION: Dans cette étude, les médecins s'identifiant à des femmes étaient moins susceptibles de percevoir qu'il y avait une équité entre les sexes en médecine d'urgence que les médecins s'identifiant à des hommes. Les femmes médecins s'accordent à dire qu'il existe davantage d'obstacles à l'avancement professionnel, notamment moins d'opportunités de leadership, un écart salarial entre les hommes et les femmes, un manque de politiques de congé parental pour favoriser le retour au travail et un manque d'éducation des hommes pour qu'ils deviennent des alliés. Les médecins s'identifiant à des hommes étaient moins conscients de ces inégalités. Les systèmes de santé doivent s'efforcer d'améliorer l'équité entre les sexes dans la médecine d'urgence, ce qui nécessitera une formation et un allié de la part des médecins qui s'identifient aux hommes.

Impact of virtual care on planned rechecks in a pediatric emergency department: a quality improvement project.

BACKGROUND: In the absence of accessible urgent follow-up options, emergency physicians may use an in-person recheck (planned return visit) to the Emergency Department (ED) as a safety net for discharged patients. In-person rechecks require travel, triage, and waiting time for patients and families and contribute to ED census. Many of these visits do not result in further investigation or changes in management but can provide reassurance for the family and care providers. We aimed to reduce the volume of in-person rechecks to our ED through an urgent virtual follow-up process. METHODS: We conducted a quality improvement project using iterative process mapping and Plan-Do-Study-Act cycles to develop and implement a new model of care for virtual rechecks. An interdisciplinary team tested and refined the virtual care process from December 2020 to June 2022. Outcome, process and balancing measures were tracked continuously and analyzed using statistical process control. RESULTS: Baseline data revealed that the majority of in-person rechecks were for young infants with bronchiolitis. Post-implementation of the new process, 50% of all virtual rechecks were for respiratory illnesses. Use of virtual rechecks increased steadily to an average of 6.5 per 1000 ED visits with 58% of all rechecks now completed virtually. The number of in-person rechecks did not decrease during the study period. Virtual rechecks triggered an in-person ED visit in 5.2% of virtual recheck instances. There was no increase in unplanned return ED visits or admissions after implementation of virtual rechecks. CONCLUSION: Virtual rechecks can be safely implemented to allow urgent reassessment of patients following an ED visit. Virtual rechecks could be a useful tool for addressing planned reassessments in the pediatric ED, especially during surges of respiratory illness.

RéSUMé: CONTEXTE: En l'absence d'options de suivi urgent accessibles, les médecins urgentistes peuvent utiliser un nouveau contrôle en personne (visite de retour planifiée) au service des urgences (SU) comme filet de sécurité pour les patients qui sortent de l'hôpital. Les contrôles en personne nécessitent des déplacements, un triage et un temps d'attente pour les patients et leurs familles, et contribuent au recensement des urgences. La plupart de ces visites n'aboutissent pas à des investigations plus poussées ou à des changements dans la prise en charge, mais elles peuvent rassurer la famille et les prestataires de soins. Notre objectif était de réduire le volume de revérifications en personne à notre service d'urgence grâce à un processus de suivi virtuel urgent. MéTHODES: Nous avons mené un projet d'amélioration de la qualité en utilisant la cartographie itérative des processus et les cycles Planifier-Faire-Étudier-Agir pour développer et mettre en œuvre un nouveau modèle de soins pour les recontrôles virtuels. Une équipe interdisciplinaire a testé et affiné le processus de soins virtuels de décembre 2020 à juin 2022. Les résultats, les processus et les mesures d'équilibre ont fait l'objet d'un suivi continu et ont été analysés à l'aide du contrôle statistique des processus. RéSULTATS: Les données de référence ont révélé que la majorité des contrôles en personne portaient sur de jeunes nourrissons atteints de bronchiolite. Après la mise en œuvre du nouveau processus, 50 % de tous les recontrôles virtuels concernaient des maladies respiratoires. Le recours aux contrôles virtuels a augmenté régulièrement pour atteindre une moyenne de 6,5 pour 1000 visites au service des urgences, 58 % de tous les contrôles étant désormais effectués virtuellement. Le nombre de revérifications en personne n'a pas diminué au cours de la période d'étude. Les recontrôles virtuels ont déclenché une visite en personne au service des urgences dans 5,2 % des cas de recontrôle virtuel. Il n'y a pas eu d'augmentation des retours non planifiés aux urgences ou des admissions après la mise en œuvre des recontrôles virtuels. CONCLUSION: Les contrôles virtuels peuvent être mis en œuvre en toute sécurité pour permettre une réévaluation urgente des patients à la suite d'une visite aux urgences. Les recontrôles virtuels pourraient être un outil utile pour les réévaluations planifiées dans les services d'urgence pédiatriques, en particulier en cas d'afflux de maladies respiratoires.

Machine learning to identify attributes that predict patients who leave without being seen in a pediatric emergency department.

PURPOSE: To characterize patients who left without being seen (LWBS) from a Canadian pediatric Emergency Department (ED) and create predictive models using machine learning to identify key attributes associated with LWBS. METHODS: We analyzed administrative ED data from April 1, 2017, to March 31, 2020, from IWK Health ED in Halifax, NS. Variables included: visit disposition; Canadian Triage Acuity Scale (CTAS); triage month, week, day, hour, minute, and day of the week; sex; age; postal code; access to primary care provider; visit payor; referral source; arrival by ambulance; main problem (ICD10); length of stay in minutes; driving distance in minutes; and ED patient load. The data were randomly divided into training (80%) and test datasets (20%). Five supervised machine learning binary classification algorithms were implemented to train models to predict LWBS patients. We balanced the dataset using Synthetic Minority Oversampling Technique (SMOTE) and used grid search for hyperparameter tuning of our models. Model evaluation was made using sensitivity and recall on the test dataset. RESULTS: The dataset included 101,266 ED visits where 2009 (2%) records were excluded and 5800 LWBS (5.7%). The highest-performing machine learning model with 16 patient attributes was XGBoost which was able to identify LWBS patients with 95% recall and 87% sensitivity. The most influential attributes in this model were ED patient load, triage hour, driving minutes from home address to ED, length of stay (minutes since triage), and age. CONCLUSION: Our analysis showed that machine learning models can be used on administrative data to predict patients who LWBS in a Canadian pediatric ED. From 16 variables, we identified the five most influential model attributes. System-level interventions to improve patient flow have shown promise for reducing LWBS in some centres. Predicting patients likely to LWBS raises the possibility of individual patient-level interventions to mitigate LWBS.

RéSUMé: BUT: Caractériser les patients qui sont partis sans être vus (left without being seen LWBS) d'un service d'urgence (SU) pédiatrique canadien et créer des modèles prédictifs utilisant l'apprentissage automatique pour identifier les attributs clés associés au LWBS. MéTHODES: Nous avons analysé les données administratives de SU du 1er avril 2017 au 31 mars 2020 provenant de l'urgence de IWK Health à Halifax, en Nouvelle-Écosse. Les variables comprenaient: disposition de la visite; l'échelle canadienne de triage de la gravité (ETG); mois, semaine, jour, heure, minute et jour de la semaine; sexe; âge; code postal; accès au fournisseur de soins primaires; payeur de la visite; source de l'aiguillage; arrivée par ambulance; principal problème (CIM10); durée du séjour en minutes; distance de conduite en minutes; et la charge de patients de l'urgence. Les données ont été divisées de manière aléatoire en ensembles de données de formation (80%) et de test (20%). Cinq algorithmes de classification binaire d'apprentissage automatique supervisés ont été mis en œuvre pour former des modèles de prévision des patients atteints de LWBS. Nous avons équilibré l'ensemble de données à l'aide de la technique de suréchantillonnage synthétique des minorités (SMOTE) et utilisé la recherche de grille pour le réglage des hyperparamètres de nos modèles. L'évaluation du modèle a été faite en utilisant la sensibilité et le rappel sur l'ensemble de données d'essai. RéSULTATS: L'ensemble de données comprenait 101266 visites aux urgences où les enregistrements de 2009 (2%) ont été exclus et 5800 LWBS (5,7%). Le modèle d'apprentissage automatique le plus performant avec 16 attributs de patient était XGBoost, qui a été en mesure d'identifier les patients LWBS avec 95% de rappel et 87% de sensibilité. Les attributs les plus influents dans ce modèle étaient la charge de patients à l'urgence, l'heure de triage, les minutes de conduite entre l'adresse du domicile et l'urgence, la durée du séjour (minutes depuis le triage) et l'âge. CONCLUSION: Notre analyse a montré que les modèles d'apprentissage automatique peuvent être utilisés sur des données administratives pour prédire les patients qui sont partis sans être vus dans un service d'urgence pédiatrique canadien. À partir de 16 variables, nous avons identifié les cinq attributs de modèle les plus influents. Les interventions au niveau du système visant à améliorer le flux de patients se sont révélées prometteuses pour réduire les LWBS dans certains centres. La prévision des patients susceptibles de LWBS soulève la possibilité d'interventions individuelles au niveau des patients pour atténuer le LWBS.

Predictors of Adherence to Short-Course Probiotics Among Children with Gastroenteritis who are Enrolled in a Clinical Trial.

BACKGROUND: To improve our understanding of adherence to discharge medications in the ED and within research trials, we sought to quantify medication adherence and identify predictors thereof in children with acute gastroenteritis (AGE). METHODS: We conducted a secondary analysis of a randomized trial of twice daily probiotic for 5 days. The population included previously healthy children aged 3-47 months with AGE. The primary outcome was patient-reported adherence to the treatment regimen, defined a priori as having received >70% of the prescribed doses. Secondary outcomes included predictors of treatment adherence and concordance between patient-reported adherence and the returned medication sachet counts. RESULTS: After excluding participants with missing data on adherence, 760 participants were included in this analysis: 383 in the probiotic arm (50.4%); and 377 in the placebo arm (49.6%). Self-reported adherence was similar in both groups (77.0% in probiotic versus 80.3% in placebo). There was good agreement between self-reported adherence and sachet counts (87% within limits of agreement (-2.9 to 3.5 sachets) on the Bland-Altman plots). In the multivariable regression model, covariates associated with adherence were greater number of days of diarrhea post-emergency department visit, and the study site; covariates negatively associated with adherence were age 12-23 months, severe dehydration and greater total number of vomiting and diarrhea episodes after enrolment. CONCLUSIONS: Longer duration of diarrhea and study site were associated with higher probiotic adherence. Age 12-23 months, severe dehydration and greater number of vomiting and diarrhea episodes post enrolment negatively predicted treatment adherence.

Intestinal Microbial Composition of Children in a Randomized Controlled Trial of Probiotics to Treat Acute Gastroenteritis.

Compositional analysis of the intestinal microbiome in pre-schoolers is understudied. Effects of probiotics on the gut microbiota were evaluated in children under 4-years-old presenting to an emergency department with acute gastroenteritis. Included were 70 study participants (n=32 placebo, n=38 probiotics) with stool specimens at baseline (day 0), day 5, and after a washout period (day 28). Microbiota composition and deduced functions were profiled using 16S ribosomal RNA sequencing and predictive metagenomics, respectively. Probiotics were detected at day 5 of administration but otherwise had no discernable effects, whereas detection of bacterial infection (P<0.001) and participant age (P<0.001) had the largest effects on microbiota composition, microbial diversity, and deduced bacterial functions. Participants under 1 year had lower bacterial diversity than older aged pre-schoolers; compositional changes of individual bacterial taxa were associated with maturation of the gut microbiota. Advances in age were associated with differences in gut microbiota composition and deduced microbial functions, which have the potential to impact health later in life. Clinical Trial Registration: www.ClinicalTrials.gov, identifier: NCT01853124.

Musculoskeletal and Head Injuries in a Canadian Summer Camp: A Three-Year Surveillance Study.

INTRODUCTION: Residential summer camps are popular among Canadian families. Campers are exposed to new, unfamiliar environments and engage in activities that may pose increased risk of injury. This study identifies the occurrence and management of musculoskeletal and head injuries at a Canadian residential summer camp. METHODS: This study was a three-year prospective observational cohort study, at a six-week Canadian residential summer camp. There were 1,388 residents, consisting of 51,546 camp days (CD). Injury data were collected by residential summer camp staff and confirmed by onsite medical professionals prior to being recorded in a secure database. Injuries were included if it was a musculoskeletal or head injury that occurred while engaged in a camp activity on or offsite, that necessitated medical attention, and that required removal or restriction from their normal camp routine for a minimum of 4 hours. RESULTS: There were 154 injuries, resulting in an incidence of 2.99 injuries per 1000 CD. Injuries were reported during scheduled activities (1.46/1000 CD) and free time (1.20/1000 CD). Sports was the most common activity during which injury occurred in all age groups (1.07/1000 CD), where males were injured twice as often as females. 65% of injuries occurred while under staff supervision. The lower extremity was the most affected body part (1.59/1000 CD). Sprains and strains accounted for 1.69 injuries/1000 CD. 83% of injuries were classified as significant and 89% of injuries were treated on-site. Over-the-counter analgesics were provided in 62% of senior camper injuries and 46% of junior camper and staff injuries. CONCLUSION: Most injuries in the residential camp setting are mild. Ensuring appropriate non-pharmacologic measures in addition to adequate analgesia may help shorten return to play.

Derivation of the Pediatric Acute Gastroenteritis Risk Score to Predict Moderate-to-Severe Acute Gastroenteritis.

OBJECTIVES: Although most acute gastroenteritis (AGE) episodes in children rapidly self-resolve, some children go on to experience more significant and prolonged illness. We sought to develop a prognostic score to identify children at risk of experiencing moderate-to-severe disease after an index emergency department (ED) visit. METHODS: Data were collected from a cohort of children 3 to 48 months of age diagnosed with AGE in 16 North American pediatric EDs. Moderate-to-severe AGE was defined as a Modified Vesikari Scale (MVS) score ≥9 during the 14-day post-ED visit. A clinical prognostic model was derived using multivariable logistic regression and converted into a simple risk score. The model's accuracy was assessed for moderate-to-severe AGE and several secondary outcomes. RESULTS: After their index ED visit, 19% (336/1770) of participants developed moderate-to-severe AGE. Patient age, number of vomiting episodes, dehydration status, prior ED visits, and intravenous rehydration were associated with MVS ≥9 in multivariable regression. Calibration of the prognostic model was strong with a P value of 0.77 by the Hosmer-Lemenshow goodness-of-fit test, and discrimination was moderate with an area under the receiver operator characteristic curve of 0.68 (95% confidence interval [CI] 0.65-0.72). Similarly, the model was shown to have good calibration when fit to the secondary outcomes of subsequent ED revisit, intravenous rehydration, or hospitalization within 72 hours after the index visit. CONCLUSIONS: After external validation, this new risk score may provide clinicians with accurate prognostic insight into the likely disease course of children with AGE, informing disposition decisions, anticipatory guidance, and follow-up care.

Organizational Interventions to Support Second Victims in Acute Care Settings: A Scoping Study.

OBJECTIVES: Health care providers that experience harm after adverse events have been termed "second victims." Our objective was to characterize the range and context of interventions to support second victims in acute care settings. METHODS: We performed a scoping study using Arksey and O'Malley's process. A library scientist searched PubMed, Cumulative Index of Nursing and Allied Health, EMBASE, and Cochrane Central Register of Controlled Trials in September 2017, and updated the search in November 2018. We sought gray literature (Canadian Electronic Library, Proquest and Scopus) and searched reference lists of included studies. Stakeholder organizations and authors of included studies were contacted. Two reviewers independently reviewed titles and abstracts and extracted data. A qualitative approach was used to categorize the context and characteristics of the 22 identified interventions. RESULTS: After screening 5634 titles and abstracts, 173 articles underwent full-text screening. Twenty-two interventions met the criteria and were categorized as providing peer support (n = 8), proactive education (n = 6), or both (n = 8). Programs came from Canada (n = 2), Spain (n = 2), and the United States (n = 18). A specific traumatic event triggered the development of 5 programs. Some programs used a standard definition of second victims, (n = 6), whereas other programs had a broader scope (n = 12). Confidentiality was explicitly assured in 9 peer support programs. Outcome measures were often not reported. CONCLUSIONS: This is a new area of study with little qualitative data from which to determine whether these programs are effective. Many programs had a similar design, based on the structure proposed by the same small group of experts in this new field. Concerns about potential legal proceedings hinder documentation and study of program effectiveness.

Variables Associated With Intravenous Rehydration and Hospitalization in Children With Acute Gastroenteritis: A Secondary Analysis of 2 Randomized Clinical Trials.

Importance: Despite guidelines endorsing oral rehydration therapy, intravenous fluids are commonly administered to children with acute gastroenteritis in high-income countries. Objective: To identify factors associated with intravenous fluid administration and hospitalization in children with acute gastroenteritis. Design, Setting, and Participants: This study is a planned secondary analysis of the Pediatric Emergency Research Canada (PERC) and Pediatric Emergency Care Applied Research Network (PECARN) probiotic trials. Participants include children aged 3 to 48 months with 3 or more watery stools in 24 hours between November 5, 2013, and April 7, 2017, for the PERC study and July 8, 2014, and June 23, 2017, for the PECARN Study. Children were from 16 pediatric emergency departments throughout Canada (6) and the US (10). Data were analyzed from November 2, 2018, to March 16, 2021. Exposures: Sex, age, preceding health care visit, distance between home and hospital, country (US vs Canada), frequency and duration of vomiting and diarrhea, presence of fever, Clinical Dehydration Scale score, oral ondansetron followed by oral rehydration therapy, and infectious agent. Main Outcomes and Measures: Intravenous fluid administration and hospitalization. Results: This secondary analysis of 2 randomized clinical trials included 1846 children (mean [SD] age, 19.1 [11.4] months; 1007 boys [54.6%]), of whom 534 of 1846 (28.9%) received oral ondansetron, 240 of 1846 (13.0%) received intravenous rehydration, and 67 of 1846 (3.6%) were hospitalized. The following were independently associated with intravenous rehydration: higher Clinical Dehydration Scale score (mild to moderate vs none, odds ratio [OR], 8.73; 95% CI, 5.81-13.13; and severe vs none, OR, 34.15; 95% CI, 13.45-86.73); country (US vs Canada, OR, 6.76; 95% CI, 3.15-14.49); prior health care visit with intravenous fluids (OR, 4.55; 95% CI, 1.32-15.72); and frequency of vomiting (per 5 episodes, OR, 1.66; 95% CI, 1.39-1.99). The following were independently associated with hospitalization: higher Clinical Dehydration Scale score (mild to moderate vs none, OR, 11.10; 95% CI, 5.05-24.38; and severe vs none, OR, 23.55; 95% CI, 7.09-78.25) and country (US vs Canada, OR, 3.37; 95% CI, 1.36-8.40). Oral ondansetron was associated with reduced odds of intravenous rehydration (OR, 0.21; 95% CI, 0.13-0.32) and hospitalization (OR, 0.44; 95% CI, 0.21-0.89). Conclusions and Relevance: Intravenous rehydration and hospitalization were associated with clinical evidence of dehydration and lack of an oral ondansetron-supported oral rehydration period. Strategies focusing on oral ondansetron administration followed by oral rehydration therapy in children with dehydration may reduce the reliance on intravenous rehydration and hospitalization. Trial Registration: ClinicalTrials.gov Identifiers: NCT01853124 (PERC) and NCT01773967 (PECARN).

A randomized trial evaluating virus-specific effects of a combination probiotic in children with acute gastroenteritis.

Gastroenteritis accounts for nearly 500,000 deaths in children younger than 5 years annually. Although probiotics have been touted as having the potential to expedite diarrhea resolution, recent clinical trials question their effectiveness. A potential explanation is a shift in pathogens following the introduction of a rotavirus vaccine. Here, we report the results of a multi-center, double-blind trial of 816 children with acute gastroenteritis who completed follow-up and provided multiple stool specimens. Participants were randomized to receive a probiotic containing Lactobacillus rhamnosus and Lactobacillus helveticus or placebo. We report no virus-specific beneficial effects attributable to the probiotic, either in reducing clinical symptoms or viral nucleic acid clearance from stool specimens collected up to 28 days following enrollment. We provide pathophysiological and microbiologic evidence to support the clinical findings and conclude that our data do not support routine probiotic administration to children with acute gastroenteritis, regardless of the infecting virus.

Pediatric Secondary Transfer Percentages: A Retrospective Observational Study.

INTRODUCTION: Certain adult conditions treated by paramedics, such as myocardial infarction or stroke, have better outcomes if transported to a specialty centre, bypassing local generalist facilities when necessary. Little evidence exists to inform guidelines to identify pediatric patients who would benefit from direct transport to a pediatric centre. This study describes the characteristics of children brought to community emergency departments (ED) who subsequently required transfer to pediatric specialty care. METHODS: A retrospective observational cohort study was performed in a metropolitan area with one tertiary pediatric specialty centre and four community EDs. The patient care record database was queried for patients under 16 years old transported by paramedics to a community ED during a five-year period. Secondary transfer to the pediatric specialty centre within 24 hours was identified. The primary outcome was percentage of transfers to specialty care. Descriptive statistics were used to characterize the whole group as well as stratified by age category, chief complaint and Canadian Triage Acuity Scale (CTAS). RESULTS: A total of 872 pediatric patients were transported to community EDs with 95 (10.9%) requiring secondary transfer to the pediatric specialty centre. CTAS 1 and 2 were associated with increased secondary transfer (p<0.001). There were also differences in transfer proportion by chief complaint. There was no association between age or gender and transfer to pediatric specialty care. CONCLUSIONS: This retrospective study shows an association between acuity and certain chief complaints and percentage of secondary transfer to pediatric specialty care.

Firearm-related injuries among Canadian children and youth from 2006 to 2013: A CHIRPP study.

OBJECTIVE: The purpose of this study was to describe Canadian contextual trends in pediatric firearm injuries and death from powder and non-powder firearms. METHODS: This is a registry study of firearm-related injuries captured by the Canadian Hospitals Injury and Reporting Prevention Program (CHIRPP) for children ages 0 to 18 years presenting to participating CHIRPP emergency departments (EDs) from 2006 to 2013. Data included age, sex, year, setting, circumstance, and disposition for each case. RESULTS: The CHIRPP dataset included 325 non-powder firearm injuries and 80 powder gun injuries. The rate of firearm injuries remained stable from 2006 to 2013 (44 per 100,000 ED visits). Forty-five patients required hospital admission and 2 died in the ED; 8 of 9 intentional self-harm injuries were inflicted with a powder gun. Most injuries occurred unintentionally from non-powder firearms (n=298, 71%) in the context of recreation (n=179) and sport (n=48). Eyes were the most commonly injured body part (n=150), 98% of which resulted from a non-powder firearm. Forty-three percent (n=141) of non-powder firearm injuries required treatment or admission. CONCLUSIONS: Eye injuries inflicted by non-powder firearms are a prevalent category of firearm-related injury. Most occurred through recreation and sport, highlighting a potential focus for primary prevention.

Summer Camp Health Initiative: An Overview of Injury and Illness in Two Canadian Summer Camps.

INTRODUCTION: Summer camp is an important part of the lives of millions of youth worldwide. Injuries and illnesses at general residential camps have not been quantified in a Canadian setting. The objective of this study was to examine the incidence of injuries and illnesses that present to camp health centres at two Canadian residential summer camps. METHOD: This prospective cross-sectional study examined the incidence of new-onset injuries and illnesses that presented to camp infirmaries and circumstances surrounding their occurrence. Data collection forms were completed by trained infirmary staff during each camper's presentation to the infirmary at two general residential camps in Canada in the summers of 2015 and 2016. RESULTS: There were 1872 infirmary presentations, resulting in a frequency of 52.6 presentations per 1000 camp days (CD). The incidence of illness was 34.8 per 1000 CD and the incidence of injury was 17.9 per 1000 CD. Communicable disease was the most common diagnosis (15.2/1000 CD), most often an upper respiratory tract infection. The most common symptoms upon presentation were sore throat (14.1/1000 CD), headache (9.9/1000 CD), runny nose/congestion (6.2/1000 CD), cough (6.0/1000 CD) and nausea and vomiting (4.8/1000 CD). The most common injuries were cuts/lacerations/bruises (4.9/1000 CD), followed by muscle/tendon injury (4.9/1000 CD). The most frequent cause of injuries was participation in sports (3.9/1000 CD) and sports fields and courts were the most frequent location for injuries to occur (2.7/1000 CD). Females accounted for 52.8% of infirmary presentations. Senior campers (ages 12-16 years) presented most frequently (43.4%), followed by junior campers (ages 6-11 years; 38.1%) and staff (age ≥17 years; 18.0%). When age-specific CDs were calculated, junior campers had the highest frequency of infirmary presentations relative to their time spent at camp (79.7/1000 CD). Fifty people (1.4/1000 CD) were sent to a hospital for further assessment. CONCLUSION: Injuries and illnesses presenting for infirmary care in summer camp are generally minor in nature. Canadian data compares similarly to United States (US) studies. Future studies should focus on interventions to reduce these injuries and illnesses, particularly communicable illnesses.

Impact of a Canadian Pediatric Society Position Statement on Trampoline-related Injuries at IWK Health Centre, Halifax, Nova Scotia.

INTRODUCTION: In 2007, the Canadian Pediatric Society (CPS) advised against the recreational use of trampolines at home and reaffirmed that statement in 2013. We evaluated the impact of this position statement on trampoline-related injuries at the IWK Health Centre in Halifax, Nova Scotia. METHODS: We completed a retrospective analysis (2001-2015) using the IWK Health Centre's Canadian Hospitals Injury Reporting and Prevention Program (CHIRPP) database. The time frame was divided into a pre-statement, post-statement, and post-reaffirmed statement. We included data on captured emergency department visits for children aged 0-16 years with trampoline-related injuries. Demographics, location, and injury mechanism were compared using the chi-squared and z tests. The proportions of trampoline injuries for pre-, post-, and post-reaffirmed statements were compared via analysis of variance (ANOVA). RESULTS: Since the CPS statement, trampoline-related injuries significantly increased at the IWK Health Centre from 0.9% to 1.6% (p<0.001). Injuries increased in children under four years old and decreased in children 10-14 years (p=0.009). Recreational use at home (93%) remained the most common location of the incident (p<0.001). Fractures (n=277) and sprains/soft tissue injuries (n=232) to the ankle, head/neck, or elbow remained the most common injuries and did not significantly change post-statement or post-reaffirmed statement (p>0.05). CONCLUSIONS: Despite the CPS statement, trampoline-related injuries remain an important source of injuries at the IWK Health Centre. The types of injury did not significantly change during this time frame.

Examining Medical Student Specialty Choice Through a Gender Lens: An Orientational Qualitative Study.

Phenomenon: A growing number of women are entering the medical workforce, yet their distribution across medical specialties remains nonuniform. We sought to describe how culture, bias, and socialization shape gendered thinking regarding specialty choice at a Canadian undergraduate medical institution. APPROACH: We analyzed transcripts from the Career Choices Project: 16 semistructured focus group discussions with 70 students graduating from Memorial University of Newfoundland in 2003, 2006, 2007, and 2008. The questions and prompts were designed to explore factors influencing specialty choice and did not specifically probe gender-based experiences. Focus groups were audio-recorded, transcribed, and deidentified before analysis. Analysis was inductive and guided by principles of orientational qualitative inquiry using a gender-specific lens. FINDINGS: The pursuits of personal and professional goals, as well as contextual factors, were the major themes that influenced decision-making for women and men. Composition of these major themes varied between genders. Influence of a partner, consideration of familial commitments (both present and future), feeling a sense of connectedness with the field in question, and social accountability were described by women as important. Both genders hoped to pursue careers that would afford "flexibility" in order to balance work with their personal lives, though the construct of work-life balance differed between genders. Women did not explicitly identify gender bias or sexism as influencing factors, but their narratives suggest that these elements were at play. Insights: Our findings suggest that unlike men, women's decision-making is informed by tension between personal and professional goals, likely related to the context of gendered personal and societal expectations.

Epidemiology of electrical and lightning-related injuries among Canadian children and youth, 1997-2010: A Canadian Hospitals Injury Reporting and Prevention Program (CHIRPP) study.

IntroductionAlthough death due to electrical injury and lightning are rare in children, these injuries are often preventable. Twenty years ago, most injuries occurred at home, precipitated by oral contact with electrical cords, contact with wall sockets and faulty electrical equipment. We sought to assess the epidemiology of electrical injuries in children presenting to Emergency Departments (EDs) that participate in the Canadian Hospitals Injury Reporting and Prevention Program (CHIRPP). METHODS: This study is a retrospective review of electrical and lightning injury data from CHIRPP. The study population included children and youth aged 0-19 presenting to participating CHIRPP EDs from 1997-2010. Age, sex, year, setting, circumstance and disposition were extracted. Variables were tested using Fisher's exact test and simple linear regression. RESULTS: The dataset included 1183 electrical injuries, with 84 (7%) resulting in hospitalization. Most events occurred at home in the 2-5 year age group and affected the hands. Since 1997 there has been a gradual decrease in the number of electrical injuries per year (p<0.01) and there is an annual surge in electrical injuries over the summer (p<0.01). Forty-six percent of injuries involved electrical outlets, 65% of injuries involved some sort of electrical equipment. Injuries due to lightning were rare (n=19). No deaths were recorded in the database. CONCLUSION: Despite the decrease in the number of electrical injuries per year, a large portion of injuries still appear to be preventable. Further research should focus on effective injury prevention strategies.

Infant Strangulation from an Amber Teething Necklace.

Amber teething necklaces supposedly provide analgesia for teething infants. Their use is becoming more widespread, despite lack of peer-reviewed evidence and warnings from Health Canada that they pose a strangulation and aspiration risk. To date, there have been no published reports of strangulation secondary to amber teething necklaces. In this report we present a case of non-fatal infant strangulation from the first time use of an amber teething necklace. We will also discuss the role of physicians as advocates in reporting similar cases and educating families. Finally, we will comment on the responsibility of all professionals and professional organizations that work with infants and toddlers to advocate for children by raising concerns and counselling parents.

A Cost Analysis of Salbutamol Administration by Metered-Dose Inhalers with Spacers versus Nebulization for Patients with Wheeze in the Pediatric Emergency Department: Evidence from Observational Data in Nova Scotia.

BACKGROUND: Despite evidence demonstrating the advantages of metered-dose inhalers with spacers (MDI-s), nebulization (NEB) remains the primary method of asthma treatment in some pediatric emergency departments (PEDs). There is a perception that delivering salbutamol by MDI-s is more costly than by NEB. This research evaluates the relative costs of MDI-s and NEB using local, hospital-specific, patient-level data. METHODS: Regression models estimated associations between the salbutamol inhalation method and costs, length of stay (LOS) in the PED and hospital, and the probability of admission. Our population was a random sample of 822 patients presenting with wheeze to the PED in 2008/2009. Control variables included age, sex, triage acuity, time of PED visit, other medications, and vitals. Costs were calculated using the prices and quantities of medical resources used per treatment. Probabilistic sensitivity analysis was used. RESULTS: Treatment with MDI-s versus NEB was associated with an absolute decrease in hospitalization of 4.4% (p<0.05) and a 25-hour (p<0.001) reduction in average inpatient stay, after controlling for triage acuity and patient characteristics. This resulted in savings of $24/patient in the PED and $180/patient overall (p<0.001). Inpatient care accounted for more than 90% of total patient costs. CONCLUSIONS: Our results suggest economic gains associated with MDI-s for salbutamol inhalation in PEDs. Sensitivity analyses show that this conclusion is not affected by changes in model parameters that may differ by jurisdiction. Since most facilities already collect the data used for this study, our methods could be adopted for a cross-jurisdictional account of the cost effectiveness of MDI-s.