Assessment of health systems guidance using the Appraisal of Guidelines for Research and Evaluation - Health Systems (AGREE-HS) instrument.

Health systems guidance (HSG) documents contain systematically developed statements or recommendations intended to address a health system challenge. The concept of HSG is fairly new and considerable effort has been undertaken to build tools to support the contextualization of recommendations. One example is the Appraisal of Guidelines for REsearch and Evaluation - Health Systems (AGREE-HS), created by international stakeholders and researchers, to assist in the development, reporting and evaluation of HSG. Here, we present the quality appraisal of 85 HSG documents published from 2012 to 2017 using the AGREE-HS. The AGREE-HS consists of five items (Topic, Participants, Methods, Recommendations, and Implementability), which are scored on a 7-point response scale (1=lowest quality; 7=highest quality). Overall, AGREE-HS item scores were highest for the 'Topic' and 'Recommendations' items (means above the mid-point of 4), while the 'Participants', 'Methods', and 'Implementability' items received lower scores. Documents without a specific health focus and those authored by the National Institute for Health and Care Excellence group, achieved higher AGREE-HS overall scores than their comparators. No statistically significant changes in overall scores were observed over time. This is the first time that the AGREE-HS has been applied, providing a current quality status report of HSG and identifying where improvements in HSG development and reporting can be made.

Blending integrated knowledge translation with global health governance: an approach for advancing action on a wicked problem.

BACKGROUND: The persistence of health inequities is a wicked problem for which there is strong evidence of causal roots in the maldistribution of power, resources and money within and between countries. Though the evidence is clear, the solutions are far from straightforward. Integrated knowledge translation (IKT) ought to be well suited for designing evidence-informed solutions, yet current frameworks are limited in their capacity to navigate complexity. Global health governance (GHG) also ought to be well suited to advance action, but a lack of accountability, inclusion and integration of evidence gives rise to politically driven action. Recognising a persistent struggle for meaningful action, we invite contemplation about how blending IKT with GHG could leverage the strengths of both processes to advance health equity. DISCUSSION: Action on root causes of health inequities implicates disruption of structures and systems that shape how society is organised. This infinitely complex work demands sophisticated examination of drivers and disrupters of inequities and a vast imagination for who (and what) should be engaged. Yet, underlying tendencies toward reductionism seem to drive superficial responses. Where IKT models lack consideration of issues of power and provide little direction for how to support cohesive efforts toward a common goal, recent calls from the field of GHG may provide insight into these issues. Additionally, though GHG is criticised for its lack of attention to using evidence, IKT offers approaches and strategies for collaborative processes of generating and refining knowledge. Contemplating the inclusion of governance in IKT requires re-examining roles, responsibilities, power and voice in processes of connecting knowledge with action. We argue for expanding IKT models to include GHG as a means of considering the complexity of issues and opening new possibilities for evidence-informed action on wicked problems. CONCLUSION: Integrated learning between these two fields, adopting principles of GHG alongside the strategies of IKT, is a promising opportunity to strengthen leadership for health equity action.

Preference-based Glaucoma-specific Health-related Quality of Life Instrument: Development of the Health Utility for Glaucoma.

PURPOSE: To develop a descriptive system for a glaucoma-specific preference-based health-related quality of life (HRQoL) instrument: the Health Utility for Glaucoma (HUG-5). METHODS: The descriptive system was developed in 2 stages: item identification and item selection. A systematic literature review of HRQoL assessment of glaucoma was conducted using a comprehensive search strategy. Purposeful sampling was used to recruit patients with different clinical characteristics. Relevant items were presented to glaucoma patients through face-to-face, semistructured interviews. Framework methodology was applied to analyze interview content. The recurring themes identified through an iterative content analysis represented topics of most importance and relevance to patients. These themes formed the domains of the HUG-5 descriptive system. Three versions of the descriptive system, differing in explanatory detail, were pilot tested using a focus group. RESULTS: The literature review identified 19 articles which contained 266 items. These items were included for the full-text review and were used to develop an interview guide. From 12 patient interviews, 22 themes were identified and grouped into 5 domains that informed the 5 questions of the descriptive system. The HUG-5 measures visual discomfort, mobility, daily life activities, emotional well-being, and social activities. Each question has 5 response levels that range from "no problem" to "severe problem." The focus group comprised 7 additional patients unanimously preferred the version that contained detailed, specific examples to support each question. CONCLUSIONS: A 5-domain descriptive system of a glaucoma-specific preference-based instrument, the HUG-5, was developed and remains to be evaluated for validity and reliability in the glaucoma patient population.

Understanding Academic Clinicians' Decision Making for the Treatment of Childhood Obesity.

BACKGROUND: Although most clinicians agree that obesity is a major problem, treatment rates remain low. We conducted this discrete choice experiment (DCE) to understand academic clinicians' decisions in treating childhood obesity. METHODS: A total of 198 academic pediatric surgeons, pediatricians, family physicians, and allied health professionals were recruited from 15 teaching hospitals across Canada to participate in this DCE. Participants completed 15 tasks choosing between three obesity treatment scenarios to identify the scenario in which they would most likely treat pediatric obesity. RESULTS: Latent class analysis revealed two classes with early intervention and late intervention preferences. Participants in the early intervention group (30%) were sensitive to variations in patient and family support. They would likely intervene if patients were obese, with normal lipid levels, were prediabetic, had high blood pressure, and when obesity was lifestyle associated. Late intervention clinicians (70%) were more likely to intervene if patients were morbidly obese, had abnormal lipid levels, required insulin for diabetes, had very high blood pressure, or when obesity impacted the patient's mental health. Simulations predicted that increasing colleague support for intervention, providing expert consultation, and mobilizing multidisciplinary support would increase the likelihood of treating pediatric obesity earlier from 16.1% to 81.5%. CONCLUSIONS: This DCE was implemented to understand the factors clinicians use in making decisions. Most academic clinicians choose to intervene late in the clinical course when more-severe obesity-related morbidities are present. Increased support from colleagues, expert consultation, and multidisciplinary support are likely to lead to earlier treatment of obesity among academic clinicians caring for children.

Risk factors for febrile urinary tract infection in children with prenatal hydronephrosis: a prospective study.

PURPOSE: We prospectively investigated the impact of risk factors for febrile urinary tract infection in infants with postnatally confirmed prenatal hydronephrosis. MATERIALS AND METHODS: Patients seen for prenatal hydronephrosis from 2010 to 2013 were prospectively followed. Those with ectopic ureters and ureteroceles, posterior urethral valves and neuropathic bladders were excluded. The primary outcome was febrile catheter specimen urinary tract infection. We performed univariate analysis of 7 a priori risk factors, including age, hydronephrosis grade (low-I or II vs high-III or IV), type (isolated hydronephrosis vs hydroureteronephrosis), continuous antibiotic prophylaxis, vesicoureteral reflux grade, gender and circumcision status. Time to febrile urinary tract infection curves analyzed by Cox proportional regression were generated to adjust for confounders. RESULTS: We collected data on 334 patients, of whom 78% were male. A febrile urinary tract infection developed in 65 patients (19%) at a median of 4 months (range 1 to 31). High grade hydronephrosis was present in 192 infants (57%). Continuous antibiotic prophylaxis was prescribed in 96 cases (29%). Of patients on continuous antibiotic prophylaxis 69% had high grade hydronephrosis. Vesicoureteral reflux was identified in 57 of 238 patients in whom voiding cystourethrogram was done. Reflux was grade I to III in 14 cases and grade IV or V in 43. Two-thirds of the patients with reflux were on continuous antibiotic prophylaxis. Circumcision was performed in 95 males (36%). Cox proportional regression identified female gender (HR 3.3, p = 0.02), uncircumcised males (HR 3.2, p = 0.02), hydroureteronephrosis (HR 10.9, p <0.01), vesicoureteral reflux (HR 20.8, p <0.01) and lack of continuous antibiotic prophylaxis (HR 5.2, p <0.01) as risk factors for febrile urinary tract infection. Subgroup analysis excluding vesicoureteral reflux showed that high grade prenatal hydronephrosis was also a significant risk factor (HR 3.0, p = 0.04). CONCLUSIONS: After patients with vesicoureteral reflux were excluded from the study, females and uncircumcised males with high grade hydroureteronephrosis had significantly higher febrile urinary tract infection rates. Therefore, those patients may benefit from continuous antibiotic prophylaxis.

Quality of reporting of the literature on gastrointestinal reflux after repair of esophageal atresia-tracheoesophageal fistula.

OBJECTIVES: There is variation in the management of postoperative gastroesophageal reflux (GER) in esophageal atresia-tracheoesophageal fistula (EA-TEF). Well-reported literature is important for clinical decision-making. We assessed the quality of reporting (QOR) of postoperative GER management in EA-TEF. METHODS: A comprehensive search of MEDLINE, EMBASE, CINHAL, CENTRAL databases and gray literature was conducted. Included articles reported a primary diagnosis of EA-TEF, a secondary diagnosis of postoperative GER, and primary treatment of GER with antireflux medications. The QOR was assessed using the STrengthening the Reporting of OBservational studies in Epidemiology (STROBE) checklist. RESULTS: Retrieval of 2910 articles resulted in 48 relevant articles (N=2592 patients) with an overall quality percentage score of 48%-95% (median=65%). The best reported items were "participants" and "outcome data" (93.8% each), "generalisability" (91.7%) and "background/rationale" (89.6%). Less than 20% of studies provided detailed "main results"; less than 5% of studies reported adequately on "bias" or "funding." Sample size calculation and study limitations were included in 17 (35.4%) and 16 (33.3%) studies respectively. Follow-up time was inconsistently reported. CONCLUSIONS: Although the overall QOR is moderate using STROBE, important areas are underreported. Inadequate methodological reporting may lead to inappropriate clinical decisions. Awareness of STROBE, emphasizing proper reporting is needed.

The level of evidence keeps improving: An updated analysis of the scientific program at the Canadian Association of Paediatric Surgeons Annual Meeting.

INTRODUCTION: The purpose of this study is to examine the scientific program of the Canadian Association of Pediatric Surgeons (CAPS) to determine if the quality of research has improved. METHODS: CAPS abstracts from 2010 to 2013 were reviewed by two independent researchers. Presentation type, study design, and level of evidence (LOE) were recorded. All differences were adjudicated by an epidemiologist. Fisher's exact test compared results to a previous study that assessed LOE in CAPS abstracts from 2005 to 2009. RESULTS: 291 abstracts were reviewed with 53 excluded and 238 included in final analysis. Reviewers demonstrated high agreement for study design (ICC=0.767 95%CI 0.715-0.810) and LOE (ICC=0.914 95%CI 0.892-0.931). Out of 238 studies, 117 (49%) were podium and 122 (51%) posters. Number of high-quality studies increased in 2010-2013 versus 2005-2009 (n=253), specifically systematic reviews (n=15 (6%) vs. n=3 (1%) p<0.01), randomized controlled trials (n=4 (2%) vs. n=0 (0%), p=0.05), and prospective cohort studies (n=41 (17%) vs. n=26 (10%), p<0.001). Retrospective cohort is still the most common. However, the number of studies has significantly decreased (n=121 (51%) vs. n=171 (68%), p<0.001). The proportion of high-level studies (LOE 2 or better) also improved (48 (20%) vs. 24 (10%) p<0.001). CONCLUSION: The quality of research presented at CAPS has greatly improved, especially in the past five years.

Compliance with published recommendations for postoperative antibiotic management of children with appendicitis: A chart audit.

BACKGROUND: Recommendations for postoperative antibiotics for appendicitis were published by the American Pediatric Surgical Association (APSA) in 2010. However, implementation of practice recommendations often takes years. We measured compliance of pediatric surgeons (who receive reminders every 6months from the Division Chief) with the APSA recommendations. METHODS: With Research Ethics Board approval, we completed a retrospective review of children who underwent appendectomy since 2010. Compliance with APSA recommendations was analyzed descriptively. Agreement between pediatric surgeons and pathologists was analyzed by kappa. RESULTS: We reviewed 242 charts. Patients were excluded for missing data (n=5) and diagnosis other than appendicitis (n=27), resulting in 210 patients with appendicitis (119 acute, 91 perforated). Agreement of perforation status between surgeons and pathologists was good (κ=0.75; 95% CI: 0.66-0.83). Many patients with nonperforated appendicitis received antibiotics in excess of the APSA recommendations (62/119 (52%)), as did those with uncomplicated perforated appendicitis (52/84 (62%)). CONCLUSIONS: Despite the availability of published recommendations, surgeons continue to prescribe postoperative antibiotics for appendicitis in excess of the recommendations. Overtreatment leads to potential medication errors and increased length-of-stay/medication costs. An intensive implementation program with ongoing education/monitoring may improve compliance with established recommendations to decrease the use of excess postoperative antibiotics and their associated costs/risks.

The burden of waiting: DALYs accrued from delayed access to pediatric surgery in Kenya and Canada.

BACKGROUND: Disability-adjusted life years (DALYs) have become the standard metric for estimating burden of disease (BoD), but have not yet been applied to delayed access to surgical procedures. This study estimates the DALYs accrued from delayed access to surgical care in two pediatric surgical units in Kenya and Canada. METHODS: Records of operations for 13 congenital health states in a Kenyan and a Canadian hospital were prospectively collected for 2012. DALYs caused by delayed presentation were estimated using disability weights and ideal and actual age at surgery. RESULTS: 1208 first-time procedures in general surgery, neurosurgery, plastic surgery, and urology were included. Delays were longest in general surgery and longer in Kenya than in Canada in all specialties. The longest delays in Kenya were for orchidopexy (72 months) and anorectoplasty (PSARP) (74 months), and in Canada for orchidopexy (40 months). Corresponding total delayed BoD was highest in general surgery and neurosurgery and higher again in Kenya than in Canada (484 cf. 84 DALYs). CONCLUSIONS: Estimating BoD resulting from delayed surgery is feasible and reflects both late presentation and limited access to care. Further exploration of these factors can make delayed DALYs a useful measure of health care coverage and waitlist prioritization.

Mortality of pediatric surgical conditions in low and middle income countries in Africa.

BACKGROUND: There are ongoing efforts to improve the quality of surgical care for children in low and middle-income countries (LMICs) in Africa. The purpose of this study was to review the recent literature and estimate the mortality associated with pediatric surgical conditions in this setting. METHODS: We completed a comprehensive search for studies that: (1) reported outcomes associated with pediatric surgical conditions; (2) were conducted in LMICs in Africa; and (3) were published between 2007 and 2012. Abstract screening, full-text review, and data abstraction were completed in duplicate. Mortality rates were pooled using a random effects model. RESULTS: Out of 2085 abstracts, 292 were selected for textual review, and 107 underwent complete data abstraction. Only 74 (68%) of these reported mortality explicitly. The highest pooled mortality rates were seen with esophageal atresia (72%), midgut volvulus (36%), and jejunoileal atresia (35%). Pooled mortality was 17% for congenital conditions and 9% for acquired disease. The overall mortality rate for all conditions was 12%. CONCLUSIONS: Mortality following pediatric surgical conditions in LMICs in Africa remains high, especially for congenital conditions in neonates. Future studies should report mortality explicitly and provide accurate follow-up data whenever possible.

Post-Operative Impact of Nasogastric Tubes on length of stay in infants with pyloric Stenosis (POINTS): A prospective randomized controlled pilot trial.

INTRODUCTION: Postoperative emesis commonly affects infants after pyloromyotomy for pyloric stenosis. This randomized controlled trial investigates the impact of preoperative nasogastric tubes (NGTs) on postoperative emesis rate and length of stay (LOS). METHODS: Patients from January 2010 to June 2012 were screened and randomized to have an 8 French NGT or no NGT inserted prior to surgery. Patients contraindicated for NGT or pyloromyotomy, those < 6 months of age, born prematurely, or with cardiac malformations were excluded. Patient demographics, blood work, postoperative feeding, postoperative emesis rate, and postoperative LOS were collected. Student's t test and Fisher's exact test were used to compare postoperative emesis rate and LOS. RESULTS: Of 125 patients screened, 65 (52%) were eligible, and 50 (77%) were recruited. The NGT (n = 25) and no NGT (n = 25) groups had no significant difference in baseline characteristics. Postoperative emesis occurred in 17 (68%) patients with NGT compared to 12 (48%) in patients with no NGT (p = 0.25). Postoperative emesis events (52 [23%] vs. 47 [20%], p = 0.50), emesis per patient (2.08 ± 2.23 vs. 1.88 ± 2.70, p = 0.76 95% CI: -1.21 to 1.61), and LOS (34.77 ± 13.74 vs. 36.33 ± 19.36, p = 0.74 95% CI: -11.11 to 7.98) were similar between NGT and no NGT groups. CONCLUSION: Preoperative NGT insertion had no demonstrable effect on LOS or postoperative emesis rate after pyloromyotomy.

A pilot randomized controlled trial evaluating the effectiveness of group vs individual urotherapy in decreasing symptoms associated with bladder-bowel dysfunction.

PURPOSE: We determined the feasibility of a definitive trial comparing the effectiveness of group vs individual urotherapy for children with bladder-bowel dysfunction. MATERIALS AND METHODS: Children 6 to 10 years old with bladder-bowel dysfunction were recruited during the course of 1 year. Feasibility data on screening, eligibility, recruitment and protocol compliance rates were collected. Patients with high grade hydronephrosis, vesicoureteral reflux or learning disabilities and those who had previously undergone urotherapy were excluded. Patients were randomized to 1-hour group urotherapy or 15-minute individual urotherapy. Symptoms and quality of life were measured using the Vancouver Nonneurogenic Lower Urinary Tract Dysfunction/Dysfunctional Elimination Syndrome Questionnaire and the Pediatric Incontinence Questionnaire at baseline and at 3 to 6 months of followup. Within/between group comparisons were conducted using t-tests. RESULTS: Of 455 screened children 79 were eligible and 60 were recruited to participate. A total of 24 patients randomized to group urotherapy and 25 randomized to individual urotherapy completed the pilot trial (6 undergoing group and 5 undergoing individual urotherapy withdrew from the study). Symptomology scores between group and individual urotherapy were not different at followup (mean ± SD 14.7 ± 7.9 vs 13.4 ± 6.3, p = 0.54, 95% CI -5.4-2.8). Quality of life scores between patients undergoing group and individual urotherapy at baseline differed (mean ± SD 21.1 ± 10.8 vs 31.0 ± 14.3, p < 0.01, 95% CI 2.7-7.3) but became similar at followup (21.0 ± 14.2 vs 20.1 ± 15.3, p = 0.84, 95% CI -9.4-7.6). Within group analyses demonstrated improvement in symptomology from baseline to followup in patients undergoing group (mean ± SD 3.6 ± 7.6, p = 0.03, 95% CI 0.4-6.8) and individual urotherapy (6.0 ± 5.4, p < 0.01, 95% CI 3.8-8.3). Within group quality of life analyses revealed improvement in Pediatric Incontinence Questionnaire scores from baseline to followup in patients undergoing individual urotherapy (p < 0.01, 95% CI 5.0-16.9) only. CONCLUSIONS: Urotherapy, regardless of modality, effectively improved bladder-bowel dysfunction symptoms. A definitive randomized controlled trial is feasible, considering that a high recruitment rate (76%) for this population has been established.

Glycerin suppositories used prophylactically in premature infants (SUPP) trial: a study protocol for a pilot randomized controlled trial.

BACKGROUND: Feeding is a significant challenge for premature infants in the neonatal intensive care unit (NICU). These patients are often treated with glycerin suppositories to stimulate the passage of meconium and prevent feeding intolerance. Unfortunately, the evidence for this practice is inconclusive. METHODS/DESIGN: This protocol is for an external pilot study that will assess the feasibility of a superiority, placebo-controlled, parallel-design, multicenter randomized controlled trial. Participants are premature infants treated in a level 3 NICU with a gestational age 24 to 32 weeks and/or birth weight of 500 to 1500 g. Thirty participants will be recruited as part of this external pilot study. Participants will be randomized to glycerin suppository (250 mg) or placebo starting 48 to 72 h after birth and continuing once daily until meconium evacuation is complete or for a maximum of 12 days. The placebo consists of a 250-mg glycerin suppository placed in the diaper rather than the rectum. Study treatments are administered by the charge nurse on duty who is not otherwise involved in patient care. All other clinicians and research personnel will remain blinded. Outcomes for the pilot study are percentage of eligible participants randomized, percentage of infants reaching full enteral feeds, cost, and treatment-related adverse events (rectal bleeding, rectal perforation, and anal fissure). DISCUSSION: This external pilot study will assess the feasibility of a multicenter randomized controlled trial of glycerin suppositories in premature infants. The subsequent multicenter trial will have sufficient power to determine whether this treatment strategy is associated with decreased time to full enteral feeds. TRIAL REGISTRATION: ClinicalTrials.gov: NCT02153606.

The management of postoperative reflux in congenital esophageal atresia-tracheoesophageal fistula: a systematic review.

PURPOSE: Esophageal atresia (EA), with or without tracheoesophageal fistula (TEF), is associated with postoperative gastroesophageal reflux (GER). We performed a systematic review of the literature regarding routine anti-reflux medication post EA-TEF repair and its impact on postoperative GER and associated complications. METHODS: A comprehensive search was conducted using MEDLINE, EMBASE, CINHAL, CENTRAL (Cochrane library) electronic databases and gray literature. Full-text screening was performed in duplicate. Included articles reported a primary diagnosis of EA-TEF, a secondary diagnosis of postoperative GER, and primary treatment of GER with anti-reflux medications. RESULTS: Screening of 2,910 articles resulted in 25 articles (1,663 patients) for analysis. Most were single-center studies (92%) and retrospective (76%); there were no randomized control trials. Fifteen studies named the class of anti-reflux agent used, 3 the duration of therapy, and none either the dose prescribed or number of doses. Complications were inconsistently reported. Anti-reflux surgery was performed in 433/1,663 (26.0%) patients. Average follow-up was 53.2 months (14 studies). CONCLUSION: The quality of literature regarding anti-reflux medication for GER post EA-TEF repair is poor. There are no well-outlined algorithms for anti-reflux agents, doses, or duration of therapy. Standardized protocols and reliable reporting are necessary to develop guidelines to better manage postoperative GER in EA-TEF patients.

Post-operative management of esophageal atresia-tracheoesophageal fistula and gastroesophageal reflux: a Canadian Association of Pediatric Surgeons annual meeting survey.

BACKGROUND: Esophageal atresia (EA), with or without tracheoesophageal fistula (TEF), is commonly associated with gastroesophageal reflux (GER) after surgical repair. One risk factor for anastomotic stricture is post-operative GER. This survey assessed practice patterns among attendees at the Canadian Association of Pediatric Surgeons (CAPS) annual meeting with respect to management of GER post EA-TEF repair. METHODS: A pre-piloted survey was handed out and collected at the 2012 CAPS annual meeting. Data were entered and coded, and descriptive statistics were calculated. RESULTS: We distributed 70 surveys, and 57 (81.4%) surveys were returned. On average, the incidence of EA-TEF is 8-10 cases per institution, per year. Anti-reflux medication is started immediately post-operatively in 74% of patients at institution of feeds (11%), or if symptoms of reflux develop (14%). Proton pump inhibitors and H2-receptor antagonists are used in approximately equal proportion. Patients are typically kept on anti-reflux medication for 3-6 months (37%) or 6-12 months (35%). CONCLUSIONS: Most CAPS attendees treat postoperative GER prophylactically. However, there is no consistency in management strategy regarding which anti-reflux agent to use or for how long. A multi-centered study is required to establish a standardized protocol for the post-operative management of EA-TEF to prevent reflux and its effect on anastomotic strictures.

Pilot randomized, placebo controlled trial to investigate the effect of antibiotic prophylaxis on the rate of urinary tract infection in infants with prenatal hydronephrosis.

PURPOSE: We determined the feasibility of a clinical trial of continuous antibiotic prophylaxis to prevent urinary tract infections in children with prenatal hydronephrosis. MATERIALS AND METHODS: We piloted a blinded, randomized, placebo controlled study of the urinary tract infection rate in infants with grades III-IV prenatal hydronephrosis at our institution between August 2010 and June 2013. Study exclusion criteria were grades I/II prenatal hydronephrosis, vesicoureteral reflux, duplication anomalies and age at randomization greater than 5 months. Prospectively collected feasibility data were obtained on eligibility, enrollment status, adherence to followup schedule, and medication and protocol compliance. RESULTS: Of 301 screened patients 220 (73.1%) were ineligible for analysis and 2 (1%) missed the randomization window. Of the remaining 81 (26.9%) eligible patients 46 were enrolled (56.8%), 29 refused (39.5%) and consent is pending in 1 (1.2%). Reasons for declining participation included parental preference for or against continuous antibiotic prophylaxis and a lack of interest in participating in clinical research. Of 46 enrolled patients 29 (63%) completed the trial, 12 (26.1%) are still in followup and 5 (10.9%) withdrew. Of the 314 medication logs dispensed 263 were returned for a 95% mean medication compliance rate. CONCLUSIONS: Based on the results of our pilot study a realistic recruitment rate for this group of patients is established, making a definitive trial of this topic feasible. However, due to the low number of eligible patients multicenter collaboration is critical to address the effect of continuous antibiotic prophylaxis on the urinary tract infection rate in this population. After study enrollment high medication and followup compliance can be expected.

Nonleg venous thrombosis in critically ill adults: a nested prospective cohort study.

IMPORTANCE: Critically ill patients are at risk of venous thrombosis, and therefore guidelines recommend daily thromboprophylaxis. Deep vein thrombosis (DVT) commonly occurs in the lower extremities but can occur in other sites including the head and neck, trunk, and upper extremities. The risk of nonleg deep venous thromboses (NLDVTs), predisposing factors, and the association between NLDVTs and pulmonary embolism (PE) or death are unclear. OBJECTIVE: To describe the frequency, anatomical location, risk factors, management, and consequences of NLDVTs in a large cohort of medical-surgical critically ill adults. DESIGN, SETTING, AND PARTICIPANTS: A nested prospective cohort study in the setting of secondary and tertiary care intensive care units (ICUs). The study population comprised 3746 patients, who were expected to remain in the ICU for at least 3 days and were enrolled in a randomized clinical trial of dalteparin vs standard heparin for thromboprophylaxis. MAIN OUTCOMES AND MEASURES: The proportion of patients who had NLDVTs, the mean number per patient, and the anatomical location. We characterized NLDVTs as prevalent or incident (identified within 72 hours of ICU admission or thereafter) and whether they were catheter related or not. We used multivariable regression models to evaluate risk factors for NLDVT and to examine subsequent anticoagulant therapy, associated PE, and death. RESULTS Of 3746 trial patients, 84 (2.2%) developed 1 or more non-leg vein thromboses (superficial or deep, proximal or distal). Thromboses were more commonly incident (n = 75 [2.0%]) than prevalent (n = 9 [0.2%]) (P < .001) and more often deep (n = 67 [1.8%]) than superficial (n = 31 [0.8%]) (P < .001). Cancer was the only independent predictor of incident NLDVT (hazard ratio [HR], 2.22; 95% CI, 1.06-4.65). After adjusting for Acute Physiology and Chronic Health Evaluation (APACHE) II scores, personal or family history of venous thromboembolism, body mass index, vasopressor use, type of thromboprophylaxis, and presence of leg DVT, NLDVTs were associated with an increased risk of PE (HR, 11.83; 95% CI, 4.80-29.18). Nonleg DVTs were not associated with ICU mortality (HR, 1.09; 95% CI, 0.62-1.92) in a model adjusting for age, APACHE II, vasopressor use, mechanical ventilation, renal replacement therapy, and platelet count below 50 × 10(9)/L. CONCLUSIONS AND RELEVANCE Despite universal heparin thromboprophylaxis, nonleg thromboses are found in 2.2% of medical-surgical critically ill patients, primarily in deep veins and proximal veins. Patients who have a malignant condition may have a significantly higher risk of developing NLDVT, and patients with NLDVT, compared with those without, appeared to be at higher risk of PE but not higher risk of death. TRIAL REGISTRATION: clinicaltrials.gov Identifier: NCT00182143.

Evaluating practice patterns in postnatal management of antenatal hydronephrosis: a national survey of Canadian pediatric urologists and nephrologists.

OBJECTIVE: To ascertain practice patterns of prescribing continuous antibiotic prophylaxis (CAP) and obtaining a voiding cystourethrogram for infants with antenatal hydronephrosis (AHN) by pediatric nephrologists and urologists across Canada. METHODS: A previously piloted online survey was distributed to members of the Canadian pediatric nephrology and urology associations. Summarized confidential responses were stratified by specialty, AHN grade, and laterality. RESULTS: A total of 88 of 139 responses were received (response rate, 63.3%; 95% confidence interval, 55.0%-71.0%): 46 nephrologists, 39 urologists, and 3 undisclosed. Only 17 of 88 (19.32%; 95% confidence interval, 12.4%-28.8%) reported following standardized AHN protocols. Concern surrounding the development of urinary tract infections was the main deciding factor for prescribing CAP (nephrology, 65.4%; urology, 71.4%). Almost a third of nephrologists (29.6%) recommend CAP for bilateral low-grade AHN compared with 11.4% of urologists (P = .02); in contrast, 73% of nephrologists and 38.2% of urologists (P = .02) offer CAP in the presence of isolated high-grade AHN. In regards to indications for voiding cystourethrogram, 31% of pediatric nephrologists would recommend this test for patients with unilateral low-grade AHN compared with 7.7% of urologists (P < .01), although almost all nephrologists (96.6%) and 69.2% of urologists (P = .02) would obtain this test for patients with unilateral high-grade isolated AHN. CONCLUSION: Our results show important practice variability between pediatric nephrologists and urologists in the management of children with AHN, which are partially explained by laterality and degree of dilation. This survey reflects the lack of treatment guidelines and supports efforts to obtain high-level evidence to develop management protocols for this common condition.

Are physicians performing neonatal circumcisions well-trained?

INTRODUCTION: Notwithstanding the recommendations from the Canadian Pediatric Association and the American Academy of Pediatrics on the indications for neonatal circumcision, this procedure is still common in North America and throughout the world. Our purpose is not to argue whether this procedure should be done, but rather to examine who is doing it, their training, how it is performed and how can we prevent unsatisfactory results and complications. The objective is to identify what fields of knowledge require improvement and then design a teaching module to improve the outcomes of neonatal circumcision. METHODS: A 19-question cross-sectional survey, including a visual identification item, was submitted to 87 physicians who perform neonatal circumcisions in Southwestern Ontario, Canada. To improve our response rate, study subjects were contacted in a variety of ways, including mail and fax and telephone. Once the survey was completed, we produced a surgical technique training video on using the Gomco clamp and the Plastibell techiques. A knowledge dissemination workshop was held with survey participants to discuss contraindications and the use of anesthesia and management of complications of neonatal circumcision and to evaluate the surgical technique training video. A 6-month follow-up questionnaire was completed to determine the impact of the teaching course on participants' daily practice. RESULTS: In total, we received 54 responses (62% response rate). From these, 46 (85%) were family doctors and pediatricians, while the remaining 8 (15%) were pediatric general surgeons and urologists. The circumcisions were carried out with the Gomco clamp 35 (63%) and the Plastibell 21 (37%). No respondent admitted to learning the procedure through a structured training course. Of the non-surgeons, 19 (43%) learned to perform a circumcision from a non-surgeon colleague. A little over a third of the participants (17, 31%) were happy to perform a circumcision in a child born with a concealed penis, where circumcision is contraindicated. With respect to the early complications post-circumcision, 8 (100%) surgeons versus 29 (63%) non-surgeons felt comfortable dealing with bleeding (p = 0.046). In total, 7 (88%) surgeons versus 16 (35%) non-surgeons were comfortable dealing with urinary retention (p = 0.01). Also, 8 (100%) surgeons versus 24 (52%) non-surgeons were comfortable dealing with a wound dehiscence (p = 0.02). Moreover, 6 (75%) surgeons and 5 (10%) non-surgeons were comfortable managing meatal stenosis (p < 0.01). Five (63%) surgeons versus 15 (33%) non-surgeons were confident in dealing with a trapped penis post-circumcision (p = 0.24). CONCLUSIONS: Our survey findings indicate that most physicians performing neonatal circumcisions in our community have received informal and unstructured training. This lack of formal instruction may explain the complications and unsatisfactory results witnessed in our pediatric urology practice. Many practitioners are not aware of the contraindications to neonatal circumcision and most non-surgeons perform the procedure without being able to handle common post-surgical complications. Based on our survey findings, we planned and carried out a formal training course to address these issues.

Outcomes of neonatal patent ductus arteriosus ligation in Canadian neonatal units with and without pediatric cardiac surgery programs.

BACKGROUND/PURPOSE: Preterm infants needing patent ductus arteriosus (PDA) ligation are transferred to a pediatric cardiac center (CC) unless the operation can be done locally by a pediatric surgeon at a non-cardiac center (NCC). We compared infant outcomes after PDA ligation at CC and NCC. METHODS: We analyzed 990 preterm infants who had PDA ligation between 2005 and 2009 using the Canadian Neonatal Network database. In-hospital mortality and major morbidities were compared between CC (n=18) and NCC (n=9). RESULTS: SNAP-II-adjusted mortality rates were similar (CC=8.7% vs NCC=10.7%, P=.32). Significant cranial ultrasound abnormalities (CC=24.1% vs NCC=32.1%, P<.01) and culture-proven sepsis (CC=39.7% vs NCC=54.8%, P<.01) were more frequent in infants treated at NCC. Infants transferred to CC had higher rates of cranial ultrasound abnormalities (transferred 31.6% vs non-transferred 20.4%, P<.01). NSAIDs prior to PDA ligation were used more often at NCC (CC 36.6% vs NCC 75.6%, P<.001). CONCLUSIONS: Mortality rates after PDA ligation were similar at CC and NCC, but cranial ultrasound abnormalities and sepsis rates were higher at NCC. Higher morbidity may be associated with different PDA management strategies, including NSAID use or infant transfer. Further studies are needed to investigate the reasons for these differences in morbidity.