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Cohen E, Quartarone S, Orkin J, Moretti ME, Emdin A, Guttmann A, Willan AR, Major N, Lim A, Diaz S, Osqui L, Soscia J, Fu L, Gandhi S, Heath A, Fayed N. Effectiveness of Structured Care Coordination for Children With Medical Complexity: The Complex Care for Kids Ontario (CCKO) Randomized Clinical Trial. JAMA Pediatr 2023; 177:461-471. [PMID: 36939728 PMCID: PMC10028546 DOI: 10.1001/jamapediatrics.2023.0115] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/21/2023]
Abstract
Importance Children with medical complexity (CMC) have chronic conditions and high health needs and may experience fragmented care. Objective To compare the effectiveness of a structured complex care program, Complex Care for Kids Ontario (CCKO), with usual care. Design, Setting, and Participants This randomized clinical trial used a waitlist variation for randomizing patients from 12 complex care clinics in Ontario, Canada, over 2 years. The study was conducted from December 2016 to June 2021. Participants were identified based on complex care clinic referral and randomly allocated into an intervention group, seen at the next available clinic appointment, or a control group that was placed on a waitlist to receive the intervention after 12 months. Intervention Assignment of a nurse practitioner-pediatrician dyad partnering with families in a structured complex care clinic to provide intensive care coordination and comprehensive plans of care. Main Outcomes and Measures Co-primary outcomes, assessed at baseline and at 6, 12, and 24 months postrandomization, were service delivery indicators from the Family Experiences With Coordination of Care that scored (1) coordination of care among health care professionals, (2) coordination of care between health care professionals and families, and (3) utility of care planning tools. Secondary outcomes included child and parent health outcomes and child health care system utilization and cost. Results Of 144 participants randomized, 141 had complete health administrative data, and 139 had complete baseline surveys. The median (IQR) age of the participants was 29 months (9-102); 83 (60%) were male. At 12 months, scores for utility of care planning tools improved in the intervention group compared with the waitlist group (adjusted odds ratio, 9.3; 95% CI, 3.9-21.9; P < .001), with no difference between groups for the other 2 co-primary outcomes. There were no group differences for secondary outcomes of child outcomes, parent outcomes, and health care system utilization and cost. At 24 months, when both groups were receiving the intervention, no primary outcome differences were observed. Total health care costs in the second year were lower for the intervention group (median, CAD$17 891; IQR, 6098-61 346; vs CAD$37 524; IQR, 9338-119 547 [US $13 415; IQR, 4572-45 998; vs US $28 136; IQR, 7002-89 637]; P = .01). Conclusions and Relevance The CCKO program improved the perceived utility of care planning tools but not other outcomes at 1 year. Extended evaluation periods may be helpful in assessing pediatric complex care interventions. Trial Registration ClinicalTrials.gov Identifier: NCT02928757.
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Affiliation(s)
- Eyal Cohen
- Child Health Evaluative Sciences, The Hospital for Sick Children, Toronto, Ontario, Canada
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
- Division of Paediatric Medicine, The Hospital for Sick Children, Toronto, Ontario, Canada
- Department of Paediatrics, University of Toronto, Toronto, Ontario, Canada
- ICES, Toronto, Ontario, Canada
- Edwin S.H. Leong Centre for Healthy Children, University of Toronto, Toronto, Ontario, Canada
| | - Samantha Quartarone
- Child Health Evaluative Sciences, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Julia Orkin
- Child Health Evaluative Sciences, The Hospital for Sick Children, Toronto, Ontario, Canada
- Division of Paediatric Medicine, The Hospital for Sick Children, Toronto, Ontario, Canada
- Department of Paediatrics, University of Toronto, Toronto, Ontario, Canada
| | - Myla E Moretti
- Child Health Evaluative Sciences, The Hospital for Sick Children, Toronto, Ontario, Canada
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
- Clinical Trials Unit, Ontario Child Health Support Unit, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Abby Emdin
- Child Health Evaluative Sciences, The Hospital for Sick Children, Toronto, Ontario, Canada
- Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
- Sunnybrook Hospital, Toronto, Ontario, Canada
| | - Astrid Guttmann
- Child Health Evaluative Sciences, The Hospital for Sick Children, Toronto, Ontario, Canada
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
- Division of Paediatric Medicine, The Hospital for Sick Children, Toronto, Ontario, Canada
- Department of Paediatrics, University of Toronto, Toronto, Ontario, Canada
- ICES, Toronto, Ontario, Canada
- Edwin S.H. Leong Centre for Healthy Children, University of Toronto, Toronto, Ontario, Canada
| | - Andrew R Willan
- Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
| | - Nathalie Major
- Department of Paediatrics, Children's Hospital of Eastern Ontario, University of Ottawa, Ottawa, Ontario, Canada
| | - Audrey Lim
- Department of Pediatrics, Hamilton Health Sciences Centre, McMaster University, Hamilton, Ontario, Canada
| | - Sanober Diaz
- Provincial Council for Maternal and Child Health, Toronto, Ontario, Canada
| | - Lisa Osqui
- Provincial Council for Maternal and Child Health, Toronto, Ontario, Canada
| | - Joanna Soscia
- Child Health Evaluative Sciences, The Hospital for Sick Children, Toronto, Ontario, Canada
- Division of Paediatric Medicine, The Hospital for Sick Children, Toronto, Ontario, Canada
- Lawrence M. Bloomberg Faculty of Nursing, University of Toronto, Toronto, Ontario, Canada
| | | | | | - Anna Heath
- Child Health Evaluative Sciences, The Hospital for Sick Children, Toronto, Ontario, Canada
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
- Division of Biostatistics, Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
- Department of Statistical Science, University College London, London, United Kingdom
| | - Nora Fayed
- School of Rehabilitation Therapy, Queen's University, Kingston, Ontario, Canada
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Eckermann S, Willan AR, Okely A, Tremblay MS, Coelli T. Robust cross-country comparison of children meeting 24-HR movement guidelines: an odds solution for binary effect efficiency measures. J Public Health (Oxf) 2022. [DOI: 10.1007/s10389-021-01587-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
Abstract
Aim
International comparisons of public health measures relative to observed best practice are increasingly important for evaluating community health promotion strategies and policies such as meeting or not meeting public health guidelines. This study aimed to identify methods enabling robust evaluation with such binary effect measures at a population level.
Subject and methods
Conventional efficiency comparisons of binary effect proportions are problematic due to a lack of consistency with alternate framing of resulting relative risks. In this paper, we illustrate such inconsistent efficiency measures comparing the proportion of school age children (9–11 years) meeting or not meeting integrated movement guidelines (IMGs) across the 12 countries from the International Study of Childhood Obesity, Lifestyle and the Environment (ISCOLE) study. IMGs jointly consider physical activity, sleep and sedentary behaviours. An odds method is developed to enable consistent efficiency comparison with alternative framing of binary effects.
Results
A novel odds solution to relative risk problems arising with conventional efficiency comparison of binary effects with alternative framing is shown to provide consistent efficiency measures relative to best practice. Furthermore, this technical advancement is shown to extend to consistent indirect comparison and evidence translation.
Conclusion
Robust methods for international cross-country comparison of binary effect measures such as meeting or not meeting guidelines are identified with a novel odds ratio method. This novel solution is particularly important for health promotion evaluation of IMGs given the need for consistent comparison in evaluating practice evidence of what works now and consistent evidence translation of treatment effects as and when they emerge.
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Orkin J, Major N, Esser K, Parmar A, Couture E, Daboval T, Kieran E, Ly L, O'Brien K, Patel H, Synnes A, Robson K, Barreira L, Smith WL, Rizakos S, Willan AR, Yaskina M, Moretti ME, Ungar WJ, Ballantyne M, Church PT, Cohen E. Coached, Coordinated, Enhanced Neonatal Transition (CCENT): protocol for a multicentre pragmatic randomised controlled trial of transition-to-home support for parents of high-risk infants. BMJ Open 2021; 11:e046706. [PMID: 34233983 PMCID: PMC8264914 DOI: 10.1136/bmjopen-2020-046706] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
INTRODUCTION Having an infant admitted to the neonatal intensive care unit (NICU) is associated with increased parental stress, anxiety and depression. Enhanced support for parents may decrease parental stress and improve subsequent parent and child outcomes. The Coached, Coordinated, Enhanced Neonatal Transition (CCENT) programme is a novel bundled intervention of psychosocial support delivered by a nurse navigator that includes Acceptance and Commitment Therapy-based coaching, care coordination and anticipatory education for parents of high-risk infants in the NICU through the first year at home. The primary objective is to evaluate the impact of the intervention on parent stress at 12 months. METHODS AND ANALYSIS This is a multicentre pragmatic randomised controlled superiority trial with 1:1 allocation to the CCENT model versus control (standard neonatal follow-up). Parents of high-risk infants (n=236) will be recruited from seven NICUs across three Canadian provinces. Intervention participants are assigned a nurse navigator who will provide the intervention for 12 months. Outcomes are measured at baseline, 6 weeks, 4, 12 and 18 months. The primary outcome measure is the total score of the Parenting Stress Index Fourth Edition Short Form at 12 months. Secondary outcomes include parental mental health, empowerment and health-related quality of life for calculation of quality-adjusted life years (QALYs). A cost-effectiveness analysis will examine the incremental cost of CCENT versus usual care per QALY gained. Qualitative interviews will explore parent and healthcare provider experiences with the intervention. ETHICS AND DISSEMINATION Research ethics approval was obtained from Clinical Trials Ontario, Children's Hospital of Eastern Ontario Research Ethics Board (REB), The Hospital for Sick Children REB, UBC Children's and Women's REB and McGill University Health Centre REB. Results will be shared with Canadian level III NICUs, neonatal follow-up programmes and academic forums. TRIAL REGISTRATION NUMBER ClinicalTrials.gov Registry (NCT03350243).
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Affiliation(s)
- Julia Orkin
- Division of Paediatric Medicine, The Hospital for Sick Children, Toronto, Ontario, Canada
- Department of Paediatrics, University of Toronto, Toronto, Ontario, Canada
- Child Health Evaluative Sciences, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Nathalie Major
- Department of Paediatrics, Children's Hospital of Eastern Ontario, Ottawa, Ontario, Canada
| | - Kayla Esser
- Child Health Evaluative Sciences, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Arpita Parmar
- Child Health Evaluative Sciences, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Elise Couture
- Division of Neonatology, Montreal Children's Hospital, Montreal, Québec, Canada
| | - Thierry Daboval
- Department of Paediatrics, Children's Hospital of Eastern Ontario, Ottawa, Ontario, Canada
| | - Emily Kieran
- Division of Neonatology, BC Women's Hospital and Health Centre, Vancouver, British Columbia, Canada
| | - Linh Ly
- Division of Neonatology, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Karel O'Brien
- Division of Neonatology, Mount Sinai Hospital, Toronto, Ontario, Canada
| | - Hema Patel
- Division of General Pediatrics, Montreal Children's Hospital, Montreal, Québec, Canada
| | - Anne Synnes
- Division of Neonatology, BC Women's Hospital and Health Centre, Vancouver, British Columbia, Canada
| | - Kate Robson
- Neonatal Follow Up Clinic, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Lesley Barreira
- Child Health Evaluative Sciences, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Wanda L Smith
- Department of Psychiatry and Behavioural Neurosciences, McMaster University, Hamilton, Ontario, Canada
| | - Sara Rizakos
- Child Health Evaluative Sciences, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Andrew R Willan
- Clinical Research Services, SickKids Research Institute, Toronto, Ontario, Canada
| | - Maryna Yaskina
- Women and Children's Health Research Institute, University of Alberta, Edmonton, Alberta, Canada
| | - Myla E Moretti
- Clinical Trials Unit, The Hospital for Sick Children, Toronto, Ontario, Canada
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
| | - Wendy J Ungar
- Child Health Evaluative Sciences, The Hospital for Sick Children, Toronto, Ontario, Canada
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
| | - Marilyn Ballantyne
- Bloorview Research Institute, Holland Bloorview Kids Rehabilitation Hospital, Toronto, Ontario, Canada
| | - Paige Terrien Church
- Department of Paediatrics, University of Toronto, Toronto, Ontario, Canada
- Division of Neonatology, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Eyal Cohen
- Division of Paediatric Medicine, The Hospital for Sick Children, Toronto, Ontario, Canada
- Department of Paediatrics, University of Toronto, Toronto, Ontario, Canada
- Child Health Evaluative Sciences, The Hospital for Sick Children, Toronto, Ontario, Canada
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Mahant S, Wahi G, Bayliss A, Giglia L, Kanani R, Pound CM, Sakran M, Kozlowski N, Breen-Reid K, Arafeh D, Moretti ME, Agarwal A, Barrowman N, Willan AR, Schuh S, Parkin PC. Intermittent vs Continuous Pulse Oximetry in Hospitalized Infants With Stabilized Bronchiolitis: A Randomized Clinical Trial. JAMA Pediatr 2021; 175:466-474. [PMID: 33646286 PMCID: PMC7922227 DOI: 10.1001/jamapediatrics.2020.6141] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
IMPORTANCE There is low level of evidence and substantial practice variation regarding the use of intermittent or continuous monitoring in infants hospitalized with bronchiolitis. OBJECTIVE To compare the effect of intermittent vs continuous pulse oximetry on clinical outcomes. DESIGN, SETTING, AND PARTICIPANTS This multicenter, pragmatic randomized clinical trial included infants 4 weeks to 24 months of age who were hospitalized with bronchiolitis from November 1, 2016, to May 31, 2019, with or without supplemental oxygen after stabilization at community and children's hospitals in Ontario, Canada. INTERVENTIONS Intermittent (every 4 hours, n = 114) or continuous (n = 115) pulse oximetry, using an oxygen saturation target of 90% or higher. MAIN OUTCOMES AND MEASURES The primary outcome was length of hospital stay from randomization to discharge. Secondary outcomes included length of stay from inpatient unit admission to discharge and outcomes measured from randomization: medical interventions, safety (intensive care unit transfer and revisits), parent anxiety and workdays missed, and nursing satisfaction. RESULTS Among 229 infants enrolled (median [IQR] age, 4.0 [2.2-8.5] months; 136 [59.4%] male; 101 [44.1%] from community hospital sites), the median length of hospital stay from randomization to discharge was 27.6 hours (interquartile range [IQR], 18.8-49.6 hours) in the intermittent group and 25.4 hours (IQR, 18.3-47.6 hours) in the continuous group (difference of medians, 2.2 hours; 95% CI, -1.9 to 6.3 hours; P = .17). No significant differences were observed between the intermittent and continuous groups in the median length of stay from inpatient unit admission to discharge: 49.1 (IQR, 37.2-87.0) hours vs 46.0 (IQR, 32.5-73.8) hours (P = .13) or in frequencies or durations of hospital interventions, such as oxygen supplementation initiation: 4 of 114 (3.5%) vs. 9 of 115 (7.8%) (P = .16) and median duration of oxygen supplementation: 20.6 (IQR, 7.6-46.1) hours vs. 21.4 (11.6-52.9) hours (P = .66). Similarly, there were no significant differences in frequencies of intensive care unit transfer: 1 of 114 (0.9%) vs 2 of 115 (2.7%) (P = .76); readmission to hospital: 3 of 114 (2.6%) in the intermittent group vs 4 of 115 (3.5%) in the continuous group (P > .99); parent anxiety: mean (SD) parent anxiety score, 2.9 (0.9) in the intermittent group vs 2.8 (0.9) in the continuous group (P = .40); or parent workdays missed: median workdays missed, 1.5 (IQR, 0.5-3.0) vs 1.5 (IQR, 0.5-2.5) (P = .36). Mean (SD) nursing satisfaction with monitoring was significantly greater in the intermittent group: 8.6 (1.7) vs 7.1 (2.8) of 10 workdays; the mean difference was 1.5 (95% CI, 0.9-2.2; P < .001). CONCLUSIONS AND RELEVANCE In this randomized clinical trial, among infants hospitalized with stabilized bronchiolitis with and without hypoxia and managed using an oxygen saturation target of 90% or higher, clinical outcomes, including length of hospital stay and safety, were similar with intermittent vs continuous pulse oximetry. Nursing satisfaction was greater with intermittent monitoring. Given that other important clinical practice considerations favor less intense monitoring, these findings support the standard use of intermittent pulse oximetry in stable infants hospitalized with bronchiolitis. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT02947204.
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Affiliation(s)
- Sanjay Mahant
- Department of Pediatrics, University of Toronto, Toronto, Ontario, Canada,Institute for Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada,Child Health Evaluative Sciences, Research Institute, Hospital for Sick Children, Toronto, Ontario, Canada
| | - Gita Wahi
- Division of General Pediatrics, Department of Pediatrics, McMaster University and McMaster Children’s Hospital, Hamilton, Ontario, Canada
| | - Ann Bayliss
- Department of Pediatrics, University of Toronto, Toronto, Ontario, Canada,Children’s Health Division, Trillium Health Partners, Mississauga, Ontario, Canada
| | - Lucy Giglia
- Division of General Pediatrics, Department of Pediatrics, McMaster University and McMaster Children’s Hospital, Hamilton, Ontario, Canada
| | - Ronik Kanani
- Department of Pediatrics, University of Toronto, Toronto, Ontario, Canada,North York General Hospital, Toronto, Ontario, Canada
| | - Catherine M. Pound
- Department of Pediatrics, Children’s Hospital of Eastern Ontario, University of Ottawa, Ottawa, Ontario, Canada
| | - Mahmoud Sakran
- Department of Pediatrics, Queens University, Kingston, Ontario, Canada,Department of Pediatrics, Lakeridge Health, Oshawa, Ontario, Canada
| | | | - Karen Breen-Reid
- Learning Institute, Hospital for Sick Children and Lawrence S. Bloomberg Faculty of Nursing, University of Toronto, Toronto, Ontario, Canada
| | - Dana Arafeh
- Child Health Evaluative Sciences, Research Institute, Hospital for Sick Children, Toronto, Ontario, Canada
| | - Myla E. Moretti
- Institute for Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada,Child Health Evaluative Sciences, Research Institute, Hospital for Sick Children, Toronto, Ontario, Canada,Ontario Child Health Support Unit, SickKids Research Institute, Toronto, Ontario, Canada
| | - Amisha Agarwal
- Children’s Hospital of Eastern Ontario Research Institute, Ottawa, Ontario, Canada
| | - Nick Barrowman
- Children’s Hospital of Eastern Ontario Research Institute, Ottawa, Ontario, Canada
| | - Andrew R. Willan
- Ontario Child Health Support Unit, SickKids Research Institute, Toronto, Ontario, Canada ,Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
| | - Suzanne Schuh
- Department of Pediatrics, University of Toronto, Toronto, Ontario, Canada,Child Health Evaluative Sciences, Research Institute, Hospital for Sick Children, Toronto, Ontario, Canada
| | - Patricia C. Parkin
- Department of Pediatrics, University of Toronto, Toronto, Ontario, Canada,Institute for Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada,Child Health Evaluative Sciences, Research Institute, Hospital for Sick Children, Toronto, Ontario, Canada
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5
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Schuh S, Sweeney J, Rumantir M, Coates AL, Willan AR, Stephens D, Atenafu EG, Finkelstein Y, Thompson G, Zemek R, Plint AC, Gravel J, Ducharme FM, Johnson DW, Black K, Curtis S, Beer D, Klassen TP, Nicksy D, Freedman SB. Effect of Nebulized Magnesium vs Placebo Added to Albuterol on Hospitalization Among Children With Refractory Acute Asthma Treated in the Emergency Department: A Randomized Clinical Trial. JAMA 2020; 324:2038-2047. [PMID: 33231663 PMCID: PMC7686869 DOI: 10.1001/jama.2020.19839] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
IMPORTANCE While intravenous magnesium decreases hospitalizations in refractory pediatric acute asthma, it is variably used because of invasiveness and safety concerns. The benefit of nebulized magnesium to prevent hospitalization is unknown. OBJECTIVE To evaluate the effectiveness of nebulized magnesium in children with acute asthma remaining in moderate or severe respiratory distress after initial therapy. DESIGN, SETTING, AND PARTICIPANTS A randomized double-blind parallel-group clinical trial from September 26, 2011, to November 19, 2019, in 7 tertiary-care pediatric emergency departments in Canada. The participants were otherwise healthy children aged 2 to 17 years with moderate to severe asthma defined by a Pediatric Respiratory Assessment Measure (PRAM) score of 5 or greater (on a 12-point scale) after a 1-hour treatment with an oral corticosteroid and 3 inhaled albuterol and ipratropium treatments. Of 5846 screened patients, 4332 were excluded for criteria, 273 declined participation, 423 otherwise excluded, 818 randomized, and 816 analyzed. INTERVENTIONS Participants were randomized to 3 nebulized albuterol treatments with either magnesium sulfate (n = 410) or 5.5% saline placebo (n = 408). MAIN OUTCOMES AND MEASURES The primary outcome was hospitalization for asthma within 24 hours. Secondary outcomes included PRAM score; respiratory rate; oxygen saturation at 60, 120, 180, and 240 minutes; blood pressure at 20, 40, 60, 120, 180, and 240 minutes; and albuterol treatments within 240 minutes. RESULTS Among 818 randomized patients (median age, 5 years; 63% males), 816 completed the trial (409 received magnesium; 407, placebo). A total of 178 of the 409 children who received magnesium (43.5%) were hospitalized vs 194 of the 407 who received placebo (47.7%) (difference, -4.2%; absolute risk difference 95% [exact] CI, -11% to 2.8%]; P = .26). There were no significant between-group differences in changes from baseline to 240 minutes in PRAM score (difference of changes, 0.14 points [95% CI, -0.23 to 0.50]; P = .46); respiratory rate (0.17 breaths/min [95% CI, -1.32 to 1.67]; P = .82); oxygen saturation (-0.04% [95% CI, -0.53% to 0.46%]; P = .88); systolic blood pressure (0.78 mm Hg [95% CI, -1.48 to 3.03]; P = .50); or mean number of additional albuterol treatments (magnesium: 1.49, placebo: 1.59; risk ratio, 0.94 [95% CI, 0.79 to 1.11]; P = .47). Nausea/vomiting or sore throat/nose occurred in 17 of the 409 children who received magnesium (4%) and 5 of the 407 who received placebo (1%). CONCLUSIONS AND RELEVANCE Among children with refractory acute asthma in the emergency department, nebulized magnesium with albuterol, compared with placebo with albuterol, did not significantly decrease the hospitalization rate for asthma within 24 hours. The findings do not support use of nebulized magnesium with albuterol among children with refractory acute asthma. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT01429415.
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Affiliation(s)
- Suzanne Schuh
- Division of Pediatric Emergency Medicine, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
- Research Institute, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Judy Sweeney
- Division of Pediatric Emergency Medicine, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Maggie Rumantir
- Division of Pediatric Emergency Medicine, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Allan L. Coates
- Division of Respiratory Medicine, Research Institute, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Andrew R. Willan
- Ontario Child Health Support Unit, SickKids Research Institute, Toronto, Ontario, Canada
- Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
| | - Derek Stephens
- Research Institute, Clinical Research Services, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Eshetu G. Atenafu
- Department of Biostatistics, Princess Margaret Cancer Centre, University of Toronto, Toronto, Ontario, Canada
| | - Yaron Finkelstein
- Research Institute, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
- Divisions of Pediatric Emergency Medicine and Clinical Pharmacology and Toxicology, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Graham Thompson
- Departments of Pediatrics and Emergency Medicine, Alberta Children’s Hospital, University of Calgary, Calgary, Alberta, Canada
- Alberta Children’s Hospital Research Institute, University of Calgary, Calgary, Alberta, Canada
| | - Roger Zemek
- Department of Pediatrics and Emergency Medicine, Children’s Hospital of Eastern Ontario, University of Ottawa, Ottawa, Ontario, Canada
- CHEO Research Institute, Ottawa, Ontario, Canada
| | - Amy C. Plint
- Department of Pediatrics and Emergency Medicine, Children’s Hospital of Eastern Ontario, University of Ottawa, Ottawa, Ontario, Canada
- CHEO Research Institute, Ottawa, Ontario, Canada
| | - Jocelyn Gravel
- Department of Pediatric Emergency Medicine, CHU Sainte-Justine, Montréal, Quebec, Canada
- Department of Pediatrics and of Social and Preventive Medicine, Université de Montréal, Montréal, Quebec, Canada
| | - Francine M. Ducharme
- Department of Pediatric Emergency Medicine, CHU Sainte-Justine, Montréal, Quebec, Canada
- Department of Pediatrics and of Social and Preventive Medicine, Université de Montréal, Montréal, Quebec, Canada
| | - David W. Johnson
- Departments of Pediatrics, Emergency Medicine, and Physiology & Pharmacology, Alberta Children’s Hospital, Calgary, Alberta, Canada
- Alberta Children’s Hospital Research Institute, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Karen Black
- Division of Pediatric Emergency Medicine, British Columbia Children’s Hospital, University of British Columbia, Vancouver, British Columbia, Canada
| | - Sarah Curtis
- Departments of Pediatrics and Emergency Medicine, Stollery Children’s Hospital, University of Alberta, Edmonton, Alberta, Canada
| | - Darcy Beer
- Pediatrics/Pediatric Emergency Medicine, University of Manitoba, Winnipeg, Manitoba, Canada
- Children’s Hospital Research Institute of Manitoba, Winnipeg, Manitoba, Canada
| | - Terry P. Klassen
- Department of Pediatrics and Child Health, University of Manitoba, Winnipeg, Manitoba, Canada
- Children’s Hospital Research Institute of Manitoba, Winnipeg, Manitoba, Canada
| | - Darcy Nicksy
- Pharmacy Department, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Stephen B. Freedman
- Sections of Pediatric Emergency Medicine and Gastroenterology, Departments of Pediatrics and Emergency Medicine, Alberta Children’s Hospital, Alberta Children’s Hospital Research Institute, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
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Dougan C, Gotha L, Melamed N, Aviram A, Asztalos EV, Anabusi S, Willan AR, Barrett J, Mei-Dan E. Cesarean delivery or induction of labor in pre-labor twin gestations: a secondary analysis of the twin birth study. BMC Pregnancy Childbirth 2020; 20:702. [PMID: 33203367 PMCID: PMC7672925 DOI: 10.1186/s12884-020-03369-x] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2020] [Accepted: 10/28/2020] [Indexed: 11/20/2022] Open
Abstract
Background In the Twin Birth Study, women at 320/7–386/7 weeks of gestation, in whom the first twin was in cephalic presentation, were randomized to planned vaginal delivery or cesarean section. The study found no significant differences in neonatal or maternal outcomes in the two planned mode of delivery groups. We aimed to compare neonatal and maternal outcomes of twin gestations without spontaneous onset of labor, who underwent induction of labor or pre-labor cesarean section as the intervention of induction may affect outcomes. Methods In this secondary analysis of the Twin Birth Study we compared those who had an induction of labor with those who had a pre-labor cesarean section. The primary outcome was a composite of fetal or neonatal death or serious neonatal morbidity. Secondary outcome was a composite of maternal morbidity and mortality. Trial Registration: NCT00187369. Results Of the 2804 women included in the Twin Birth Study, a total of 1347 (48%) women required a delivery before a spontaneous onset of labor occurred: 568 (42%) in the planned vaginal delivery arm and 779 (58%) in the planned cesarean arm. Induction of labor was attempted in 409 (30%), and 938 (70%) had a pre-labor cesarean section. The rate of intrapartum cesarean section in the induction of labor group was 41.3%. The rate of the primary outcome was comparable between the pre-labor cesarean section group and induction of labor group (1.65% vs. 1.97%; p = 0.61; OR 0.83; 95% CI 0.43–1.62). The maternal composite outcome was found to be lower with pre-labor cesarean section compared to induction of labor (7.25% vs. 11.25%; p = 0.01; OR 0.61; 95% CI 0.41–0.91). Conclusion In women with twin gestation between 320/7–386/7 weeks of gestation, induction of labor and pre-labor cesarean section have similar neonatal outcomes. Pre-labor cesarean section is associated with favorable maternal outcomes which differs from the overall Twin Birth Study results. These data may be used to better counsel women with twin gestation who are faced with the decision of interventional delivery. Supplementary Information The online version contains supplementary material available at 10.1186/s12884-020-03369-x.
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Affiliation(s)
- C Dougan
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology and the Department of Newborn & Developmental Paediatrics, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada.,Department of Obstetrics and Gynecology, North York General Hospital, Toronto, ON, Canada.,University of Toronto, Toronto, ON, Canada
| | - L Gotha
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology and the Department of Newborn & Developmental Paediatrics, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada.,University of Toronto, Toronto, ON, Canada
| | - N Melamed
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology and the Department of Newborn & Developmental Paediatrics, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada.,University of Toronto, Toronto, ON, Canada
| | - A Aviram
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology and the Department of Newborn & Developmental Paediatrics, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada.,University of Toronto, Toronto, ON, Canada
| | - E V Asztalos
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology and the Department of Newborn & Developmental Paediatrics, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada.,University of Toronto, Toronto, ON, Canada
| | - S Anabusi
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology and the Department of Newborn & Developmental Paediatrics, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada.,Department of Obstetrics and Gynecology, North York General Hospital, Toronto, ON, Canada.,University of Toronto, Toronto, ON, Canada
| | - A R Willan
- University of Toronto, Toronto, ON, Canada.,Child Health Evaluative Sciences, SickKids Research Institute, The Hospital for Sick Children, Toronto, ON, Canada
| | - Jfr Barrett
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology and the Department of Newborn & Developmental Paediatrics, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada.,University of Toronto, Toronto, ON, Canada
| | - E Mei-Dan
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology and the Department of Newborn & Developmental Paediatrics, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada. .,Department of Obstetrics and Gynecology, North York General Hospital, Toronto, ON, Canada. .,University of Toronto, Toronto, ON, Canada.
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7
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Abstract
Background/aims: The use of pilot studies to help inform the design of randomized controlled trials has increased significantly over the last couple of decades. A pilot study can provide estimates of feasibility parameters, such as the recruitment, compliance and follow-up probabilities. The use of frequentist confidence intervals of these estimates fails to provide a meaningful measure of the uncertainty as it pertains to the design of the associated randomized controlled trial. The objective of this article is to introduce Bayesian methods for the analysis of pilot studies for determining the feasibility of an associated randomized controlled trial. Methods: An example from the literature is used to illustrate the advantages of a Bayesian approach for accounting for the uncertainty in pilot study results when assessing the feasibility of an associated randomized controlled trial. Vague beta distribution priors for the feasibility parameters are used. Based on the results from a feasibility study, simulation methods are used to determine the expected power of specified recruitment strategies for an associated randomized controlled trial. Results: The vague priors used for the feasibility parameters are demonstrated to be considerably robust. Beta distribution posteriors for the feasibility parameters lead to beta-binomial predictive distributions for an associated randomized controlled trial regarding the number of patients randomized, the number of patients who are compliant and the number of patients who complete follow-up. Ignoring the uncertainty in pilot study results can lead to inadequate power for an associated randomized controlled trial. Conclusion: Applying Bayesian methods to pilot studies’ results provides direct inference about the feasibility parameters and quantifies the uncertainty regarding the feasibility of an associated randomized controlled trial in an intuitive and meaningful way. Furthermore, Bayesian methods can identify recruitment strategies that yield the desired power for an associated randomized controlled trial.
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Affiliation(s)
- Andrew R Willan
- Ontario Child Health Support Unit, SickKids Research Institute, Toronto, ON, Canada
- Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada
| | - Lehana Thabane
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
- Biostatistics Unit, St Joseph’s Healthcare, Hamilton, ON, Canada
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8
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Lemire O, Yaraskavitch J, Lougheed J, Mackie AS, Norozi K, Graham J, Willan AR, Longmuir PE. Impacting child health outcomes in congenital heart disease: Cluster randomized controlled trial protocol of in-clinic physical activity counselling. Contemp Clin Trials 2020; 91:105994. [PMID: 32222326 DOI: 10.1016/j.cct.2020.105994] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2019] [Revised: 03/09/2020] [Accepted: 03/18/2020] [Indexed: 11/15/2022]
Abstract
BACKGROUND Most (>90%) children with congenital health defects are not active enough for optimal health. Proactively promoting physical activity during every clinic visit is recommended, but rarely implemented due to a lack of appropriate resources. METHODS This cluster randomized controlled trial will implement an evidence-based, multi-faceted physical activity intervention. All eligible patients at small (London, ON), medium (Ottawa, ON) and large (Edmonton, AB) pediatric cardiac clinics will be approached, with randomization to intervention/control by clinic and week. Intervention patients will be counselled with 5 key physical activity messages, have questions about physical activity answered, and have access to a custom web site with personalized activity suggestions and support from a Registered Kinesiologist. The primary outcome is daily physical activity (number of steps, minutes of moderate-to-vigorous activity) assessed via pedometer one week per month for 6-months. Standardized questionnaires assess activity motivation and quality of life at baseline and end of study. Healthcare outcomes will be clinic visit time and contacts for physical activity concerns. Repeated measures ANCOVA will compare control/intervention pedometer outcomes, adjusting for covariates (alpha=0.05). CONCLUSIONS This trial aims to determine whether providing resources and protocols enables clinicians to counsel about physical activity as part of every pediatric cardiology appointment. Evaluations of healthcare system impact and intervention delivery in small, medium and large clinics will assess applicability for implementation in all pediatric cardiac clinics. The impact on physical activity motivation and participation will evaluate the effectiveness of this standardized approach for increasing physical activity in children with congenital heart defects.
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Affiliation(s)
- Olivia Lemire
- Children's Hospital of Eastern Ontario Research Institute, Ottawa, Ontario, Canada; University of Ottawa, Faculty of Medicine, Ottawa, Ontario, Canada
| | - Jenna Yaraskavitch
- Children's Hospital of Eastern Ontario Research Institute, Ottawa, Ontario, Canada
| | - Jane Lougheed
- Children's Hospital of Eastern Ontario Research Institute, Ottawa, Ontario, Canada; Children's Hospital of Eastern Ontario, Ottawa, Ontario, Canada
| | - Andrew S Mackie
- Stollery Children's Hospital, Department of Pediatrics, Division of Cardiology, University of Alberta, Edmonton, Alberta, Canada
| | - Kambiz Norozi
- Department of Pediatrics, Pediatric Cardiology, Schulich School of Medicine and Dentistry, Western University & Children's Health Research Institute, London, Ontario, Canada; Paediatric Cardiology and Intensive Care Medicine, Medical School Hannover, Germany
| | - Jennifer Graham
- Canadian Congenital Heart Alliance, Toronto, Ontario, Canada
| | | | - Patricia E Longmuir
- Children's Hospital of Eastern Ontario Research Institute, Ottawa, Ontario, Canada; University of Ottawa, Faculty of Medicine, Ottawa, Ontario, Canada.
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9
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Bueno M, Stevens B, Barwick MA, Riahi S, Li SA, Lanese A, Willan AR, Synnes A, Estabrooks CA, Chambers CT, Harrison D, Yamada J, Stinson J, Campbell-Yeo M, Noel M, Gibbins S, LeMay S, Isaranuwatchai W. A cluster randomized clinical trial to evaluate the effectiveness of the Implementation of Infant Pain Practice Change (ImPaC) Resource to improve pain practices in hospitalized infants: a study protocol. Trials 2020; 21:16. [PMID: 31907017 PMCID: PMC6945403 DOI: 10.1186/s13063-019-3782-9] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2019] [Accepted: 10/09/2019] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND Hospitalized infants undergo multiple painful procedures daily. Despite the significant evidence, procedural pain assessment and management continues to be suboptimal. Repetitive and untreated pain at this vital developmental juncture is associated with negative behavioral and neurodevelopmental consequences. To address this knowledge to practice gap, we developed the web-based Implementation of Infant Pain Practice Change (ImPaC) Resource to guide change in healthcare professionals' pain practice behaviors. This protocol describes the evaluation of the intervention effectiveness and implementation of the Resource and how organizational context influences outcomes. METHODS An effectiveness-implementation hybrid type 1 design, blending a cluster randomized clinical trial and a mixed-methods implementation study will be used. Eighteen Neonatal Intensive Care Units (NICUs) across Canada will be randomized to intervention (INT) or standard practice (SP) groups. NICUs in the INT group will receive the Resource for six months; those in the SP group will continue with practice as usual and will be offered the Resource after a six-month waiting period. Data analysts will be blinded to group allocation. To address the intervention effectiveness, the INT and SP groups will be compared on clinical outcomes including the proportion of infants who have procedural pain assessed and managed, and the frequency and nature of painful procedures. Data will be collected at baseline (before randomization) and at completion of the intervention (six months). Implementation outcomes (feasibility, fidelity, implementation cost, and reach) will be measured at completion of the intervention. Sustainability will be assessed at six and 12 months following the intervention. Organizational context will be assessed to examine its influence on intervention and implementation outcomes. DISCUSSION This mixed-methods study aims to determine the effectiveness and the implementation of a multifaceted online strategy for changing healthcare professionals' pain practices for hospitalized infants. Implementation strategies that are easily and effectively implemented are important for sustained change. The results will inform healthcare professionals and decision-makers on how to address the challenges of implementing the Resource within various organizational contexts. TRIAL REGISTRATION ClinicalTrials.gov, NCT03825822. Registered 31 January 2019.
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Affiliation(s)
- Mariana Bueno
- Child Health and Evaluative Sciences, The Hospital for Sick Children, Peter Gilgan Centre for Research and Learning (PGCRL), 686 Bay Street, 6th floor, Toronto, M5G 0A4, Canada
| | - Bonnie Stevens
- Child Health and Evaluative Sciences, The Hospital for Sick Children, Peter Gilgan Centre for Research and Learning (PGCRL), 686 Bay Street, 6th floor, Toronto, M5G 0A4, Canada. .,Lawrence S. Bloomberg Faculty of Nursing & Faculties of Medicine and Dentistry, University of Toronto, 155 College Street, M5T 1P8, Toronto, Canada.
| | - Melanie A Barwick
- Child Health and Evaluative Sciences, The Hospital for Sick Children, Peter Gilgan Centre for Research and Learning (PGCRL), 686 Bay Street, 6th floor, Toronto, M5G 0A4, Canada.,Department of Psychiatry, Faculty of Medicine, University of Toronto, 250 College Street, M5T 1R8, Toronto, Canada.,Dalla Lana School of Public Health, University of Toronto, 155 College Street, M5T 3M7, Toronto, Canada
| | - Shirine Riahi
- Child Health and Evaluative Sciences, The Hospital for Sick Children, Peter Gilgan Centre for Research and Learning (PGCRL), 686 Bay Street, 6th floor, Toronto, M5G 0A4, Canada
| | - Shelly-Anne Li
- Child Health and Evaluative Sciences, The Hospital for Sick Children, Peter Gilgan Centre for Research and Learning (PGCRL), 686 Bay Street, 6th floor, Toronto, M5G 0A4, Canada.,Lawrence S. Bloomberg Faculty of Nursing & Faculties of Medicine and Dentistry, University of Toronto, 155 College Street, M5T 1P8, Toronto, Canada
| | - Alexa Lanese
- Child Health and Evaluative Sciences, The Hospital for Sick Children, Peter Gilgan Centre for Research and Learning (PGCRL), 686 Bay Street, 6th floor, Toronto, M5G 0A4, Canada
| | - Andrew R Willan
- Child Health and Evaluative Sciences, The Hospital for Sick Children, Peter Gilgan Centre for Research and Learning (PGCRL), 686 Bay Street, 6th floor, Toronto, M5G 0A4, Canada.,Dalla Lana School of Public Health, University of Toronto, 155 College Street, M5T 3M7, Toronto, Canada
| | - Anne Synnes
- University of British Columbia, Pediatrics, Rm. 1N18, 4480 Oak Street, Vancouver, British Columbia, V6H 3V4, Canada
| | - Carole A Estabrooks
- University of Alberta, Edmonton Health Clinic Academy, Rm 5-006 11405 87 Avenue NW, T6G 1C9, Edmonton, Alberta, Canada
| | - Christine T Chambers
- Departments of Pediatrics and Psychology & Neuroscience, Dalhousie University and Centre for Pediatric Pain Research, IWK Health Centre, P.O. Box 9700 5850-5980 University Ave, Halifax, Nova Scotia, B3K 6R8, Canada
| | - Denise Harrison
- School of Nursing, Faculty of Health Sciences, University of Ottawa, and Children's Hospital of Eastern Ontario, 401 Smyth Road, Ottawa, K1H 8L1, Canada
| | - Janet Yamada
- Ryerson University, Daphne Cockwell School of Nursing, 350 Victoria Street, Toronto, Ontario, M5B 2K3, Canada
| | - Jennifer Stinson
- Child Health and Evaluative Sciences, The Hospital for Sick Children, Peter Gilgan Centre for Research and Learning (PGCRL), 686 Bay Street, 6th floor, Toronto, M5G 0A4, Canada.,Lawrence S. Bloomberg Faculty of Nursing & Faculties of Medicine and Dentistry, University of Toronto, 155 College Street, M5T 1P8, Toronto, Canada
| | - Marsha Campbell-Yeo
- School of Nursing, Faculty of Health, Departments of Pediatrics and Psychology & Neuroscience, Dalhousie University and Centre for Pediatric Pain Research, IWK Health Centre, 5869 University Ave, Halifax, B3H 4R2, Canada
| | - Melanie Noel
- Department of Psychology, University of Calgary, Psychology, Rm. 260, Administration Building, 539 Campus Place NW, T2N 4V8, Calgary, Canada.,Alberta Children's Hospital Research Institute, Hotchkiss Brain Institute, Owekro Centre, Calgary, Alberta, Canada
| | - Sharyn Gibbins
- Trillium Health Partners, Professional Practice, 2200 Eglinton Ave W, Mississauga, Ontario, L5M 2N1, Canada
| | - Sylvie LeMay
- Université de Montréal, Faculty of Nursing and CHU Sainte-Justine's Research Centre, 3175 Chemin de la Côte-Sainte-Catherine, Montreal, Quebec, H3T 1C5, Canada
| | - Wanrudee Isaranuwatchai
- Institute for Health Policy, Management and Evaluation, University of Toronto, 155 College Street, M5T 3M7, Toronto, Canada.,St. Michael's Hospital, 30 Bond Street, Toronto, Ontario, M5B 1W8, Canada
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10
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Freedman SB, Soofi SB, Willan AR, Williamson-Urquhart S, Siddiqui E, Xie J, Dawoud F, Bhutta ZA. Oral Ondansetron Administration to Dehydrated Children in Pakistan: A Randomized Clinical Trial. Pediatrics 2019; 144:peds.2019-2161. [PMID: 31694979 DOI: 10.1542/peds.2019-2161] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/04/2019] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND Ondansetron is an effective antiemetic employed to prevent vomiting in children with gastroenteritis in high-income countries; data from low- and middle-income countries are sparse. METHODS We conducted a randomized, double-blind, placebo-controlled superiority trial in 2 pediatric emergency departments in Pakistan. Dehydrated children aged 6 to 60 months with ≥1 diarrheal (ie, loose or liquid) stool and ≥1 vomiting episode within the preceding 4 hours were eligible to participate. Participants received a single weight-based dose of oral ondansetron (8-15 kg: 2 mg; >15 kg: 4 mg) or identical placebo. The primary outcome was intravenous administration of ≥20 mL/kg over 4 hours of an isotonic fluid within 72 hours of random assignment. RESULTS All 918 (100%) randomly assigned children completed follow-up. Intravenous rehydration was administered to 14.7% (68 of 462) and 19.5% (89 of 456) of those administered ondansetron and placebo, respectively (difference: -4.8%; 95% confidence interval [CI], -9.7% to 0.0%). In multivariable logistic regression analysis adjusted for other antiemetic agents, antibiotics, zinc, and the number of vomiting episodes in the preceding 24 hours, children administered ondansetron had lower odds of the primary outcome (odds ratio: 0.70; 95% CI, 0.49 to 1.00). Fewer children in the ondansetron, relative to the placebo group vomited during the observation period (difference: -12.9%; 95% CI, -18.0% to -7.8%). The median number of vomiting episodes (P < .001) was lower in the ondansetron group. CONCLUSIONS Among children with gastroenteritis-associated vomiting and dehydration, oral ondansetron administration reduced vomiting and intravenous rehydration use. Ondansetron use may be considered to promote oral rehydration therapy success among dehydrated children in low- and middle-income countries.
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Affiliation(s)
- Stephen B Freedman
- Sections of Pediatric Emergency Medicine and Gastroenterology, Department of Pediatrics, Alberta Children's Hospital and Alberta Children's Hospital Research Institute and
| | - Sajid B Soofi
- Centre of Excellence in Women and Child Health, The Aga Khan University, Karachi, Pakistan
| | - Andrew R Willan
- Ontario Child Health Support Unit, SickKids Research Institute, Toronto, Ontario, Canada; and
| | - Sarah Williamson-Urquhart
- Section of Pediatric Emergency Medicine, Department of Pediatrics, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Emaduddin Siddiqui
- Centre of Excellence in Women and Child Health, The Aga Khan University, Karachi, Pakistan
| | - Jianling Xie
- Section of Pediatric Emergency Medicine, Department of Pediatrics, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Fady Dawoud
- Section of Pediatric Emergency Medicine, Department of Pediatrics, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Zulfiqar A Bhutta
- Centre of Excellence in Women and Child Health, The Aga Khan University, Karachi, Pakistan.,Centre for Global Child Health, The Hospital for Sick Children, Toronto, Ontario, Canada
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11
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Orkin J, Chan CY, Fayed N, Lin JLL, Major N, Lim A, Peebles ER, Moretti ME, Soscia J, Sultan R, Willan AR, Offringa M, Guttmann A, Bartlett L, Kanani R, Culbert E, Hardy-Brown K, Gordon M, Perlmutar M, Cohen E. Complex care for kids Ontario: protocol for a mixed-methods randomised controlled trial of a population-level care coordination initiative for children with medical complexity. BMJ Open 2019; 9:e028121. [PMID: 31375613 PMCID: PMC6688698 DOI: 10.1136/bmjopen-2018-028121] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/07/2023] Open
Abstract
INTRODUCTION Technological and medical advances have led to a growing population of children with medical complexity (CMC) defined by substantial medical needs, healthcare utilisation and morbidity. These children are at a high risk of missed, fragmented and/or inappropriate care, and families bear extraordinary financial burden and stress. While small in number (<1% of children), this group uses ~1/3 of all child healthcare resources, and need coordinated care to optimise their health. Complex care for kids Ontario (CCKO) brings researchers, families and healthcare providers together to develop, implement and evaluate a population-level roll-out of care for CMC in Ontario, Canada through a randomised controlled trial (RCT) design. The intervention includes dedicated key workers and the utilisation of coordinated shared care plans. METHODS AND ANALYSIS Our primary objective is to evaluate the CCKO intervention using a randomised waitlist control design. The waitlist approach involves rolling out an intervention over time, whereby all participants are randomised into two groups (A and B) to receive the intervention at different time points determined at random. Baseline measurements are collected at month 0, and groups A and B are compared at months 6 and 12. The primary outcome is the family-prioritized Family Experiences with Coordination of Care (FECC) survey at 12 months. The FECC will be compared between groups using an analysis of covariance with the corresponding baseline score as the covariate. Secondary outcomes include reports of child and parent health outcomes, health system utilisation and process outcomes. ETHICS AND DISSEMINATION Research ethics approval has been obtained for this multicentre RCT. This trial will assess the effect of a large population-level complex care intervention to determine whether dedicated key workers and coordinated care plans have an impact on improving service delivery and quality of life for CMC and their families. TRIAL REGISTRATION NUMBER NCT02928757.
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Affiliation(s)
- Julia Orkin
- Division of Pediatric Medicine, The Hospital for Sick Children, Toronto, Ontario, Canada
- Department of Pediatrics, University of Toronto, Toronto, Ontario, Canada
| | - Carol Y Chan
- Child Health Evaluative Sciences, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Nora Fayed
- School of Rehabilitation Therapy, Queen's University, Kingston, Ontario, Canada
| | - Jia Lu Lilian Lin
- Institute of Health Policy, Management and Evaluation, University of Toronto Dalla Lana School of Public Health, Toronto, Ontario, Canada
| | - Nathalie Major
- Department of Paediatrics, Children's Hospital of Eastern Ontario, Ottawa, Ontario, Canada
| | - Audrey Lim
- Department of Pediatrics, Hamilton Health Sciences Center, McMaster University, Hamilton, Ontario, Canada
| | - Erin R Peebles
- Department of Pediatrics, Western University, London, Ontario, Canada
| | - Myla E Moretti
- Clinical Trials Unit, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Joanna Soscia
- Division of Pediatric Medicine, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Roxana Sultan
- The Provincial Council for Maternal and Child Health, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Andrew R Willan
- Clinical Trials Unit, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Martin Offringa
- Child Health Evaluative Sciences, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Astrid Guttmann
- Division of Pediatric Medicine, The Hospital for Sick Children, Toronto, Ontario, Canada
- Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada
| | - Leah Bartlett
- Department of Pediatrics, Royal Victoria Regional Health Centre, Barrie, Ontario, Canada
| | - Ronik Kanani
- Department of Pediatrics, North York General Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Erin Culbert
- The Credit Valley Hospital, Trillium Health Partners, Mississauga, Ontario, Canada
| | | | - Michelle Gordon
- Department of Pediatrics, Orillia Soldier's Memorial Hospital, Orillia, Ontario, Canada
| | - Marty Perlmutar
- Department of Pediatrics, Michael Garron Hospital, Toronto, Ontario, Canada
| | - Eyal Cohen
- Division of Pediatric Medicine, The Hospital for Sick Children, Toronto, Ontario, Canada
- Department of Pediatrics, University of Toronto, Toronto, Ontario, Canada
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12
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Mei-Dan E, Dougan C, Melamed N, Asztalos EV, Aviram A, Willan AR, Barrett JFR. Planned cesarean or vaginal delivery for women in spontaneous labor with a twin pregnancy: A secondary analysis of the Twin Birth Study. Birth 2019; 46:193-200. [PMID: 30073688 DOI: 10.1111/birt.12387] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/26/2018] [Revised: 07/01/2018] [Accepted: 07/01/2018] [Indexed: 11/30/2022]
Abstract
BACKGROUND The Twin Birth Study, a multicenter randomized controlled trial, found no differences in neonatal outcomes in women with twins randomized to planned cesarean or vaginal delivery. Nevertheless, women who present in spontaneous labor might expect a better outcome following a trial of vaginal delivery than undergoing cesarean delivery. In this secondary analysis, we aimed to compare neonatal outcomes of women who presented in spontaneous labor in the two arms of the Twin Birth Study. METHODS Women in whom the first twin was in the cephalic presentation were randomized between 32 + 0 and 38 + 6 weeks to planned vaginal delivery or cesarean. The primary outcome was a composite of fetal or neonatal death or serious neonatal morbidity. RESULTS Of the 2804 women included in the Twin Birth Study, 823 women in the planned vaginal delivery arm and 612 in the planned cesarean arm presented in spontaneous labor. Although the odds ratio favored planned vaginal delivery, there was no statistically significant difference in the rate of primary outcome between the vaginal delivery and cesarean arms (1.8% vs 2.7%, respectively; P = 0.16; OR 1.49; 95% CI, 0.87-2.55). Similarly, the rates of the individual components of the primary outcome and of maternal adverse outcome were similar between the two arms. CONCLUSION In women with twins who present in spontaneous labor between 32 + 0 and 38 + 6 weeks' gestation, where the first twin is cephalic, a policy of planned vaginal delivery or cesarean is not associated with significant differences in neonatal or maternal outcomes.
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Affiliation(s)
- Elad Mei-Dan
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology and the Department of Newborn & Developmental Paediatrics, Sunnybrook Health Sciences Centre, Toronto, ON, Canada.,Department of Obstetrics and Gynecology, North York General Hospital, Toronto, ON, Canada.,University of Toronto, Toronto, ON, Canada
| | - Claire Dougan
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology and the Department of Newborn & Developmental Paediatrics, Sunnybrook Health Sciences Centre, Toronto, ON, Canada.,Department of Obstetrics and Gynecology, North York General Hospital, Toronto, ON, Canada.,University of Toronto, Toronto, ON, Canada
| | - Nir Melamed
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology and the Department of Newborn & Developmental Paediatrics, Sunnybrook Health Sciences Centre, Toronto, ON, Canada.,University of Toronto, Toronto, ON, Canada
| | - Elizabeth V Asztalos
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology and the Department of Newborn & Developmental Paediatrics, Sunnybrook Health Sciences Centre, Toronto, ON, Canada.,University of Toronto, Toronto, ON, Canada
| | - Amir Aviram
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology and the Department of Newborn & Developmental Paediatrics, Sunnybrook Health Sciences Centre, Toronto, ON, Canada.,University of Toronto, Toronto, ON, Canada
| | - Andrew R Willan
- University of Toronto, Toronto, ON, Canada.,Child Health Evaluative Sciences, SickKids Research Institute, The Hospital for Sick Children, Toronto, ON, Canada
| | - Jon F R Barrett
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology and the Department of Newborn & Developmental Paediatrics, Sunnybrook Health Sciences Centre, Toronto, ON, Canada.,University of Toronto, Toronto, ON, Canada
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13
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Aviram A, Asztalos EV, Mei-Dan E, Willan AR, Melamed N, Zaltz A, Anastasio HB, Berghella V, Barrett J. 133: Worst of both worlds - combined deliveries in twins: lessons from the Twin Birth Study. Am J Obstet Gynecol 2019. [DOI: 10.1016/j.ajog.2018.11.154] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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14
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Aviram A, Asztalos EV, Mei-Dan E, Willan AR, Melamed N, Zaltz A, Hvidman L, Barrett J. 132: Delivery of monochorionic twins - Sub-analysis of the Twin Birth Study. Am J Obstet Gynecol 2019. [DOI: 10.1016/j.ajog.2018.11.153] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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15
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Freedman SB, Williamson-Urquhart S, Farion KJ, Gouin S, Willan AR, Poonai N, Hurley K, Sherman PM, Finkelstein Y, Lee BE, Pang XL, Chui L, Schnadower D, Xie J, Gorelick M, Schuh S. Multicenter Trial of a Combination Probiotic for Children with Gastroenteritis. N Engl J Med 2018; 379:2015-2026. [PMID: 30462939 DOI: 10.1056/nejmoa1802597] [Citation(s) in RCA: 124] [Impact Index Per Article: 20.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
BACKGROUND Gastroenteritis accounts for approximately 1.7 million visits to the emergency department (ED) by children in the United States every year. Data to determine whether the use of probiotics improves outcomes in these children are lacking. METHODS We conducted a randomized, double-blind trial involving 886 children 3 to 48 months of age with gastroenteritis who presented to six pediatric EDs in Canada. Participants received a 5-day course of a combination probiotic product containing Lactobacillus rhamnosus R0011 and L. helveticus R0052, at a dose of 4.0×109 colony-forming units twice daily or placebo. The primary outcome was moderate-to-severe gastroenteritis, which was defined according to a post-enrollment modified Vesikari scale symptom score of 9 or higher (scores range from 0 to 20, with higher scores indicating more severe disease). Secondary outcomes included the duration of diarrhea and vomiting, the percentage of children who had unscheduled physician visits, and the presence or absence of adverse events. RESULTS Moderate-to-severe gastroenteritis within 14 days after enrollment occurred in 108 of 414 participants (26.1%) who were assigned to probiotics and 102 of 413 participants (24.7%) who were assigned to placebo (odds ratio, 1.06; 95% confidence interval [CI], 0.77 to 1.46; P=0.72). After adjustment for trial site, age, detection of rotavirus in stool, and frequency of diarrhea and vomiting before enrollment, trial-group assignment did not predict moderate-to-severe gastroenteritis (odds ratio, 1.06; 95% CI, 0.76 to 1.49; P=0.74). There were no significant differences between the probiotic group and the placebo group in the median duration of diarrhea (52.5 hours [interquartile range, 18.3 to 95.8] and 55.5 hours [interquartile range, 20.2 to 102.3], respectively; P=0.31) or vomiting (17.7 hours [interquartile range, 0 to 58.6] and 18.7 hours [interquartile range, 0 to 51.6], P=0.18), the percentages of participants with unscheduled visits to a health care provider (30.2% and 26.6%; odds ratio, 1.19; 95% CI, 0.87 to 1.62; P=0.27), and the percentage of participants who reported an adverse event (34.8% and 38.7%; odds ratio, 0.83; 95% CI, 0.62 to 1.11; P=0.21). CONCLUSIONS In children who presented to the emergency department with gastroenteritis, twice-daily administration of a combined L. rhamnosus-L. helveticus probiotic did not prevent the development of moderate-to-severe gastroenteritis within 14 days after enrollment. (Funded by the Canadian Institutes of Health Research and others; PROGUT ClinicalTrials.gov number, NCT01853124 .).
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Affiliation(s)
- Stephen B Freedman
- From the Sections of Pediatric Emergency Medicine and Gastroenterology, Alberta Children's Hospital, Alberta Children's Hospital Research Institute (S.B.F.), and the Section of Pediatric Emergency Medicine, Alberta Children's Hospital (S.W.-U., J.X.), Cumming School of Medicine, University of Calgary, Calgary, the Departments of Pediatrics and Emergency Medicine, Children's Hospital of Eastern Ontario, University of Ottawa, Ottawa (K.J.F.), the Division of Pediatric Emergency Medicine, Department of Pediatrics, Centre Hospitalier Universitaire Sainte-Justine, Université de Montréal, Montreal (S.G.), Ontario Child Health Support Unit, SickKids Research Institute, the Division of Biostatistics, Dalla Lana School of Public Health (A.R.W.), the Division of Gastroenterology, Hepatology, and Nutrition (P.M.S.), the Divisions of Pediatric Emergency Medicine and Clinical Pharmacology and Toxicology (Y.F.), and the Division of Pediatric Emergency Medicine and Research Institute (S.S.), Hospital for Sick Children, University of Toronto, Toronto, the Division of Emergency Medicine, London Health Sciences Centre, Department of Pediatrics, Schulich School of Medicine and Dentistry, Western University, London, ON (N.P.), the Division of Pediatric Emergency Medicine, IWK Health Centre, Halifax, NS (K.H.), the Department of Pediatrics, Faculty of Medicine and Dentistry, Women and Children's Health Research Institute (B.E.L.) and the Provincial Laboratory for Public Health-Alberta Public Laboratories and Department of Laboratory Medicine and Pathology (X.-L.P., L.C.), University of Alberta, Edmonton - all in Canada; the Division of Pediatric Emergency Medicine, Washington University School of Medicine, St. Louis (D.S.); and Children's Minnesota and Department of Pediatrics, University of Minnesota Medical School, Minneapolis (M.G.)
| | - Sarah Williamson-Urquhart
- From the Sections of Pediatric Emergency Medicine and Gastroenterology, Alberta Children's Hospital, Alberta Children's Hospital Research Institute (S.B.F.), and the Section of Pediatric Emergency Medicine, Alberta Children's Hospital (S.W.-U., J.X.), Cumming School of Medicine, University of Calgary, Calgary, the Departments of Pediatrics and Emergency Medicine, Children's Hospital of Eastern Ontario, University of Ottawa, Ottawa (K.J.F.), the Division of Pediatric Emergency Medicine, Department of Pediatrics, Centre Hospitalier Universitaire Sainte-Justine, Université de Montréal, Montreal (S.G.), Ontario Child Health Support Unit, SickKids Research Institute, the Division of Biostatistics, Dalla Lana School of Public Health (A.R.W.), the Division of Gastroenterology, Hepatology, and Nutrition (P.M.S.), the Divisions of Pediatric Emergency Medicine and Clinical Pharmacology and Toxicology (Y.F.), and the Division of Pediatric Emergency Medicine and Research Institute (S.S.), Hospital for Sick Children, University of Toronto, Toronto, the Division of Emergency Medicine, London Health Sciences Centre, Department of Pediatrics, Schulich School of Medicine and Dentistry, Western University, London, ON (N.P.), the Division of Pediatric Emergency Medicine, IWK Health Centre, Halifax, NS (K.H.), the Department of Pediatrics, Faculty of Medicine and Dentistry, Women and Children's Health Research Institute (B.E.L.) and the Provincial Laboratory for Public Health-Alberta Public Laboratories and Department of Laboratory Medicine and Pathology (X.-L.P., L.C.), University of Alberta, Edmonton - all in Canada; the Division of Pediatric Emergency Medicine, Washington University School of Medicine, St. Louis (D.S.); and Children's Minnesota and Department of Pediatrics, University of Minnesota Medical School, Minneapolis (M.G.)
| | - Ken J Farion
- From the Sections of Pediatric Emergency Medicine and Gastroenterology, Alberta Children's Hospital, Alberta Children's Hospital Research Institute (S.B.F.), and the Section of Pediatric Emergency Medicine, Alberta Children's Hospital (S.W.-U., J.X.), Cumming School of Medicine, University of Calgary, Calgary, the Departments of Pediatrics and Emergency Medicine, Children's Hospital of Eastern Ontario, University of Ottawa, Ottawa (K.J.F.), the Division of Pediatric Emergency Medicine, Department of Pediatrics, Centre Hospitalier Universitaire Sainte-Justine, Université de Montréal, Montreal (S.G.), Ontario Child Health Support Unit, SickKids Research Institute, the Division of Biostatistics, Dalla Lana School of Public Health (A.R.W.), the Division of Gastroenterology, Hepatology, and Nutrition (P.M.S.), the Divisions of Pediatric Emergency Medicine and Clinical Pharmacology and Toxicology (Y.F.), and the Division of Pediatric Emergency Medicine and Research Institute (S.S.), Hospital for Sick Children, University of Toronto, Toronto, the Division of Emergency Medicine, London Health Sciences Centre, Department of Pediatrics, Schulich School of Medicine and Dentistry, Western University, London, ON (N.P.), the Division of Pediatric Emergency Medicine, IWK Health Centre, Halifax, NS (K.H.), the Department of Pediatrics, Faculty of Medicine and Dentistry, Women and Children's Health Research Institute (B.E.L.) and the Provincial Laboratory for Public Health-Alberta Public Laboratories and Department of Laboratory Medicine and Pathology (X.-L.P., L.C.), University of Alberta, Edmonton - all in Canada; the Division of Pediatric Emergency Medicine, Washington University School of Medicine, St. Louis (D.S.); and Children's Minnesota and Department of Pediatrics, University of Minnesota Medical School, Minneapolis (M.G.)
| | - Serge Gouin
- From the Sections of Pediatric Emergency Medicine and Gastroenterology, Alberta Children's Hospital, Alberta Children's Hospital Research Institute (S.B.F.), and the Section of Pediatric Emergency Medicine, Alberta Children's Hospital (S.W.-U., J.X.), Cumming School of Medicine, University of Calgary, Calgary, the Departments of Pediatrics and Emergency Medicine, Children's Hospital of Eastern Ontario, University of Ottawa, Ottawa (K.J.F.), the Division of Pediatric Emergency Medicine, Department of Pediatrics, Centre Hospitalier Universitaire Sainte-Justine, Université de Montréal, Montreal (S.G.), Ontario Child Health Support Unit, SickKids Research Institute, the Division of Biostatistics, Dalla Lana School of Public Health (A.R.W.), the Division of Gastroenterology, Hepatology, and Nutrition (P.M.S.), the Divisions of Pediatric Emergency Medicine and Clinical Pharmacology and Toxicology (Y.F.), and the Division of Pediatric Emergency Medicine and Research Institute (S.S.), Hospital for Sick Children, University of Toronto, Toronto, the Division of Emergency Medicine, London Health Sciences Centre, Department of Pediatrics, Schulich School of Medicine and Dentistry, Western University, London, ON (N.P.), the Division of Pediatric Emergency Medicine, IWK Health Centre, Halifax, NS (K.H.), the Department of Pediatrics, Faculty of Medicine and Dentistry, Women and Children's Health Research Institute (B.E.L.) and the Provincial Laboratory for Public Health-Alberta Public Laboratories and Department of Laboratory Medicine and Pathology (X.-L.P., L.C.), University of Alberta, Edmonton - all in Canada; the Division of Pediatric Emergency Medicine, Washington University School of Medicine, St. Louis (D.S.); and Children's Minnesota and Department of Pediatrics, University of Minnesota Medical School, Minneapolis (M.G.)
| | - Andrew R Willan
- From the Sections of Pediatric Emergency Medicine and Gastroenterology, Alberta Children's Hospital, Alberta Children's Hospital Research Institute (S.B.F.), and the Section of Pediatric Emergency Medicine, Alberta Children's Hospital (S.W.-U., J.X.), Cumming School of Medicine, University of Calgary, Calgary, the Departments of Pediatrics and Emergency Medicine, Children's Hospital of Eastern Ontario, University of Ottawa, Ottawa (K.J.F.), the Division of Pediatric Emergency Medicine, Department of Pediatrics, Centre Hospitalier Universitaire Sainte-Justine, Université de Montréal, Montreal (S.G.), Ontario Child Health Support Unit, SickKids Research Institute, the Division of Biostatistics, Dalla Lana School of Public Health (A.R.W.), the Division of Gastroenterology, Hepatology, and Nutrition (P.M.S.), the Divisions of Pediatric Emergency Medicine and Clinical Pharmacology and Toxicology (Y.F.), and the Division of Pediatric Emergency Medicine and Research Institute (S.S.), Hospital for Sick Children, University of Toronto, Toronto, the Division of Emergency Medicine, London Health Sciences Centre, Department of Pediatrics, Schulich School of Medicine and Dentistry, Western University, London, ON (N.P.), the Division of Pediatric Emergency Medicine, IWK Health Centre, Halifax, NS (K.H.), the Department of Pediatrics, Faculty of Medicine and Dentistry, Women and Children's Health Research Institute (B.E.L.) and the Provincial Laboratory for Public Health-Alberta Public Laboratories and Department of Laboratory Medicine and Pathology (X.-L.P., L.C.), University of Alberta, Edmonton - all in Canada; the Division of Pediatric Emergency Medicine, Washington University School of Medicine, St. Louis (D.S.); and Children's Minnesota and Department of Pediatrics, University of Minnesota Medical School, Minneapolis (M.G.)
| | - Naveen Poonai
- From the Sections of Pediatric Emergency Medicine and Gastroenterology, Alberta Children's Hospital, Alberta Children's Hospital Research Institute (S.B.F.), and the Section of Pediatric Emergency Medicine, Alberta Children's Hospital (S.W.-U., J.X.), Cumming School of Medicine, University of Calgary, Calgary, the Departments of Pediatrics and Emergency Medicine, Children's Hospital of Eastern Ontario, University of Ottawa, Ottawa (K.J.F.), the Division of Pediatric Emergency Medicine, Department of Pediatrics, Centre Hospitalier Universitaire Sainte-Justine, Université de Montréal, Montreal (S.G.), Ontario Child Health Support Unit, SickKids Research Institute, the Division of Biostatistics, Dalla Lana School of Public Health (A.R.W.), the Division of Gastroenterology, Hepatology, and Nutrition (P.M.S.), the Divisions of Pediatric Emergency Medicine and Clinical Pharmacology and Toxicology (Y.F.), and the Division of Pediatric Emergency Medicine and Research Institute (S.S.), Hospital for Sick Children, University of Toronto, Toronto, the Division of Emergency Medicine, London Health Sciences Centre, Department of Pediatrics, Schulich School of Medicine and Dentistry, Western University, London, ON (N.P.), the Division of Pediatric Emergency Medicine, IWK Health Centre, Halifax, NS (K.H.), the Department of Pediatrics, Faculty of Medicine and Dentistry, Women and Children's Health Research Institute (B.E.L.) and the Provincial Laboratory for Public Health-Alberta Public Laboratories and Department of Laboratory Medicine and Pathology (X.-L.P., L.C.), University of Alberta, Edmonton - all in Canada; the Division of Pediatric Emergency Medicine, Washington University School of Medicine, St. Louis (D.S.); and Children's Minnesota and Department of Pediatrics, University of Minnesota Medical School, Minneapolis (M.G.)
| | - Katrina Hurley
- From the Sections of Pediatric Emergency Medicine and Gastroenterology, Alberta Children's Hospital, Alberta Children's Hospital Research Institute (S.B.F.), and the Section of Pediatric Emergency Medicine, Alberta Children's Hospital (S.W.-U., J.X.), Cumming School of Medicine, University of Calgary, Calgary, the Departments of Pediatrics and Emergency Medicine, Children's Hospital of Eastern Ontario, University of Ottawa, Ottawa (K.J.F.), the Division of Pediatric Emergency Medicine, Department of Pediatrics, Centre Hospitalier Universitaire Sainte-Justine, Université de Montréal, Montreal (S.G.), Ontario Child Health Support Unit, SickKids Research Institute, the Division of Biostatistics, Dalla Lana School of Public Health (A.R.W.), the Division of Gastroenterology, Hepatology, and Nutrition (P.M.S.), the Divisions of Pediatric Emergency Medicine and Clinical Pharmacology and Toxicology (Y.F.), and the Division of Pediatric Emergency Medicine and Research Institute (S.S.), Hospital for Sick Children, University of Toronto, Toronto, the Division of Emergency Medicine, London Health Sciences Centre, Department of Pediatrics, Schulich School of Medicine and Dentistry, Western University, London, ON (N.P.), the Division of Pediatric Emergency Medicine, IWK Health Centre, Halifax, NS (K.H.), the Department of Pediatrics, Faculty of Medicine and Dentistry, Women and Children's Health Research Institute (B.E.L.) and the Provincial Laboratory for Public Health-Alberta Public Laboratories and Department of Laboratory Medicine and Pathology (X.-L.P., L.C.), University of Alberta, Edmonton - all in Canada; the Division of Pediatric Emergency Medicine, Washington University School of Medicine, St. Louis (D.S.); and Children's Minnesota and Department of Pediatrics, University of Minnesota Medical School, Minneapolis (M.G.)
| | - Philip M Sherman
- From the Sections of Pediatric Emergency Medicine and Gastroenterology, Alberta Children's Hospital, Alberta Children's Hospital Research Institute (S.B.F.), and the Section of Pediatric Emergency Medicine, Alberta Children's Hospital (S.W.-U., J.X.), Cumming School of Medicine, University of Calgary, Calgary, the Departments of Pediatrics and Emergency Medicine, Children's Hospital of Eastern Ontario, University of Ottawa, Ottawa (K.J.F.), the Division of Pediatric Emergency Medicine, Department of Pediatrics, Centre Hospitalier Universitaire Sainte-Justine, Université de Montréal, Montreal (S.G.), Ontario Child Health Support Unit, SickKids Research Institute, the Division of Biostatistics, Dalla Lana School of Public Health (A.R.W.), the Division of Gastroenterology, Hepatology, and Nutrition (P.M.S.), the Divisions of Pediatric Emergency Medicine and Clinical Pharmacology and Toxicology (Y.F.), and the Division of Pediatric Emergency Medicine and Research Institute (S.S.), Hospital for Sick Children, University of Toronto, Toronto, the Division of Emergency Medicine, London Health Sciences Centre, Department of Pediatrics, Schulich School of Medicine and Dentistry, Western University, London, ON (N.P.), the Division of Pediatric Emergency Medicine, IWK Health Centre, Halifax, NS (K.H.), the Department of Pediatrics, Faculty of Medicine and Dentistry, Women and Children's Health Research Institute (B.E.L.) and the Provincial Laboratory for Public Health-Alberta Public Laboratories and Department of Laboratory Medicine and Pathology (X.-L.P., L.C.), University of Alberta, Edmonton - all in Canada; the Division of Pediatric Emergency Medicine, Washington University School of Medicine, St. Louis (D.S.); and Children's Minnesota and Department of Pediatrics, University of Minnesota Medical School, Minneapolis (M.G.)
| | - Yaron Finkelstein
- From the Sections of Pediatric Emergency Medicine and Gastroenterology, Alberta Children's Hospital, Alberta Children's Hospital Research Institute (S.B.F.), and the Section of Pediatric Emergency Medicine, Alberta Children's Hospital (S.W.-U., J.X.), Cumming School of Medicine, University of Calgary, Calgary, the Departments of Pediatrics and Emergency Medicine, Children's Hospital of Eastern Ontario, University of Ottawa, Ottawa (K.J.F.), the Division of Pediatric Emergency Medicine, Department of Pediatrics, Centre Hospitalier Universitaire Sainte-Justine, Université de Montréal, Montreal (S.G.), Ontario Child Health Support Unit, SickKids Research Institute, the Division of Biostatistics, Dalla Lana School of Public Health (A.R.W.), the Division of Gastroenterology, Hepatology, and Nutrition (P.M.S.), the Divisions of Pediatric Emergency Medicine and Clinical Pharmacology and Toxicology (Y.F.), and the Division of Pediatric Emergency Medicine and Research Institute (S.S.), Hospital for Sick Children, University of Toronto, Toronto, the Division of Emergency Medicine, London Health Sciences Centre, Department of Pediatrics, Schulich School of Medicine and Dentistry, Western University, London, ON (N.P.), the Division of Pediatric Emergency Medicine, IWK Health Centre, Halifax, NS (K.H.), the Department of Pediatrics, Faculty of Medicine and Dentistry, Women and Children's Health Research Institute (B.E.L.) and the Provincial Laboratory for Public Health-Alberta Public Laboratories and Department of Laboratory Medicine and Pathology (X.-L.P., L.C.), University of Alberta, Edmonton - all in Canada; the Division of Pediatric Emergency Medicine, Washington University School of Medicine, St. Louis (D.S.); and Children's Minnesota and Department of Pediatrics, University of Minnesota Medical School, Minneapolis (M.G.)
| | - Bonita E Lee
- From the Sections of Pediatric Emergency Medicine and Gastroenterology, Alberta Children's Hospital, Alberta Children's Hospital Research Institute (S.B.F.), and the Section of Pediatric Emergency Medicine, Alberta Children's Hospital (S.W.-U., J.X.), Cumming School of Medicine, University of Calgary, Calgary, the Departments of Pediatrics and Emergency Medicine, Children's Hospital of Eastern Ontario, University of Ottawa, Ottawa (K.J.F.), the Division of Pediatric Emergency Medicine, Department of Pediatrics, Centre Hospitalier Universitaire Sainte-Justine, Université de Montréal, Montreal (S.G.), Ontario Child Health Support Unit, SickKids Research Institute, the Division of Biostatistics, Dalla Lana School of Public Health (A.R.W.), the Division of Gastroenterology, Hepatology, and Nutrition (P.M.S.), the Divisions of Pediatric Emergency Medicine and Clinical Pharmacology and Toxicology (Y.F.), and the Division of Pediatric Emergency Medicine and Research Institute (S.S.), Hospital for Sick Children, University of Toronto, Toronto, the Division of Emergency Medicine, London Health Sciences Centre, Department of Pediatrics, Schulich School of Medicine and Dentistry, Western University, London, ON (N.P.), the Division of Pediatric Emergency Medicine, IWK Health Centre, Halifax, NS (K.H.), the Department of Pediatrics, Faculty of Medicine and Dentistry, Women and Children's Health Research Institute (B.E.L.) and the Provincial Laboratory for Public Health-Alberta Public Laboratories and Department of Laboratory Medicine and Pathology (X.-L.P., L.C.), University of Alberta, Edmonton - all in Canada; the Division of Pediatric Emergency Medicine, Washington University School of Medicine, St. Louis (D.S.); and Children's Minnesota and Department of Pediatrics, University of Minnesota Medical School, Minneapolis (M.G.)
| | - Xiao-Li Pang
- From the Sections of Pediatric Emergency Medicine and Gastroenterology, Alberta Children's Hospital, Alberta Children's Hospital Research Institute (S.B.F.), and the Section of Pediatric Emergency Medicine, Alberta Children's Hospital (S.W.-U., J.X.), Cumming School of Medicine, University of Calgary, Calgary, the Departments of Pediatrics and Emergency Medicine, Children's Hospital of Eastern Ontario, University of Ottawa, Ottawa (K.J.F.), the Division of Pediatric Emergency Medicine, Department of Pediatrics, Centre Hospitalier Universitaire Sainte-Justine, Université de Montréal, Montreal (S.G.), Ontario Child Health Support Unit, SickKids Research Institute, the Division of Biostatistics, Dalla Lana School of Public Health (A.R.W.), the Division of Gastroenterology, Hepatology, and Nutrition (P.M.S.), the Divisions of Pediatric Emergency Medicine and Clinical Pharmacology and Toxicology (Y.F.), and the Division of Pediatric Emergency Medicine and Research Institute (S.S.), Hospital for Sick Children, University of Toronto, Toronto, the Division of Emergency Medicine, London Health Sciences Centre, Department of Pediatrics, Schulich School of Medicine and Dentistry, Western University, London, ON (N.P.), the Division of Pediatric Emergency Medicine, IWK Health Centre, Halifax, NS (K.H.), the Department of Pediatrics, Faculty of Medicine and Dentistry, Women and Children's Health Research Institute (B.E.L.) and the Provincial Laboratory for Public Health-Alberta Public Laboratories and Department of Laboratory Medicine and Pathology (X.-L.P., L.C.), University of Alberta, Edmonton - all in Canada; the Division of Pediatric Emergency Medicine, Washington University School of Medicine, St. Louis (D.S.); and Children's Minnesota and Department of Pediatrics, University of Minnesota Medical School, Minneapolis (M.G.)
| | - Linda Chui
- From the Sections of Pediatric Emergency Medicine and Gastroenterology, Alberta Children's Hospital, Alberta Children's Hospital Research Institute (S.B.F.), and the Section of Pediatric Emergency Medicine, Alberta Children's Hospital (S.W.-U., J.X.), Cumming School of Medicine, University of Calgary, Calgary, the Departments of Pediatrics and Emergency Medicine, Children's Hospital of Eastern Ontario, University of Ottawa, Ottawa (K.J.F.), the Division of Pediatric Emergency Medicine, Department of Pediatrics, Centre Hospitalier Universitaire Sainte-Justine, Université de Montréal, Montreal (S.G.), Ontario Child Health Support Unit, SickKids Research Institute, the Division of Biostatistics, Dalla Lana School of Public Health (A.R.W.), the Division of Gastroenterology, Hepatology, and Nutrition (P.M.S.), the Divisions of Pediatric Emergency Medicine and Clinical Pharmacology and Toxicology (Y.F.), and the Division of Pediatric Emergency Medicine and Research Institute (S.S.), Hospital for Sick Children, University of Toronto, Toronto, the Division of Emergency Medicine, London Health Sciences Centre, Department of Pediatrics, Schulich School of Medicine and Dentistry, Western University, London, ON (N.P.), the Division of Pediatric Emergency Medicine, IWK Health Centre, Halifax, NS (K.H.), the Department of Pediatrics, Faculty of Medicine and Dentistry, Women and Children's Health Research Institute (B.E.L.) and the Provincial Laboratory for Public Health-Alberta Public Laboratories and Department of Laboratory Medicine and Pathology (X.-L.P., L.C.), University of Alberta, Edmonton - all in Canada; the Division of Pediatric Emergency Medicine, Washington University School of Medicine, St. Louis (D.S.); and Children's Minnesota and Department of Pediatrics, University of Minnesota Medical School, Minneapolis (M.G.)
| | - David Schnadower
- From the Sections of Pediatric Emergency Medicine and Gastroenterology, Alberta Children's Hospital, Alberta Children's Hospital Research Institute (S.B.F.), and the Section of Pediatric Emergency Medicine, Alberta Children's Hospital (S.W.-U., J.X.), Cumming School of Medicine, University of Calgary, Calgary, the Departments of Pediatrics and Emergency Medicine, Children's Hospital of Eastern Ontario, University of Ottawa, Ottawa (K.J.F.), the Division of Pediatric Emergency Medicine, Department of Pediatrics, Centre Hospitalier Universitaire Sainte-Justine, Université de Montréal, Montreal (S.G.), Ontario Child Health Support Unit, SickKids Research Institute, the Division of Biostatistics, Dalla Lana School of Public Health (A.R.W.), the Division of Gastroenterology, Hepatology, and Nutrition (P.M.S.), the Divisions of Pediatric Emergency Medicine and Clinical Pharmacology and Toxicology (Y.F.), and the Division of Pediatric Emergency Medicine and Research Institute (S.S.), Hospital for Sick Children, University of Toronto, Toronto, the Division of Emergency Medicine, London Health Sciences Centre, Department of Pediatrics, Schulich School of Medicine and Dentistry, Western University, London, ON (N.P.), the Division of Pediatric Emergency Medicine, IWK Health Centre, Halifax, NS (K.H.), the Department of Pediatrics, Faculty of Medicine and Dentistry, Women and Children's Health Research Institute (B.E.L.) and the Provincial Laboratory for Public Health-Alberta Public Laboratories and Department of Laboratory Medicine and Pathology (X.-L.P., L.C.), University of Alberta, Edmonton - all in Canada; the Division of Pediatric Emergency Medicine, Washington University School of Medicine, St. Louis (D.S.); and Children's Minnesota and Department of Pediatrics, University of Minnesota Medical School, Minneapolis (M.G.)
| | - Jianling Xie
- From the Sections of Pediatric Emergency Medicine and Gastroenterology, Alberta Children's Hospital, Alberta Children's Hospital Research Institute (S.B.F.), and the Section of Pediatric Emergency Medicine, Alberta Children's Hospital (S.W.-U., J.X.), Cumming School of Medicine, University of Calgary, Calgary, the Departments of Pediatrics and Emergency Medicine, Children's Hospital of Eastern Ontario, University of Ottawa, Ottawa (K.J.F.), the Division of Pediatric Emergency Medicine, Department of Pediatrics, Centre Hospitalier Universitaire Sainte-Justine, Université de Montréal, Montreal (S.G.), Ontario Child Health Support Unit, SickKids Research Institute, the Division of Biostatistics, Dalla Lana School of Public Health (A.R.W.), the Division of Gastroenterology, Hepatology, and Nutrition (P.M.S.), the Divisions of Pediatric Emergency Medicine and Clinical Pharmacology and Toxicology (Y.F.), and the Division of Pediatric Emergency Medicine and Research Institute (S.S.), Hospital for Sick Children, University of Toronto, Toronto, the Division of Emergency Medicine, London Health Sciences Centre, Department of Pediatrics, Schulich School of Medicine and Dentistry, Western University, London, ON (N.P.), the Division of Pediatric Emergency Medicine, IWK Health Centre, Halifax, NS (K.H.), the Department of Pediatrics, Faculty of Medicine and Dentistry, Women and Children's Health Research Institute (B.E.L.) and the Provincial Laboratory for Public Health-Alberta Public Laboratories and Department of Laboratory Medicine and Pathology (X.-L.P., L.C.), University of Alberta, Edmonton - all in Canada; the Division of Pediatric Emergency Medicine, Washington University School of Medicine, St. Louis (D.S.); and Children's Minnesota and Department of Pediatrics, University of Minnesota Medical School, Minneapolis (M.G.)
| | - Marc Gorelick
- From the Sections of Pediatric Emergency Medicine and Gastroenterology, Alberta Children's Hospital, Alberta Children's Hospital Research Institute (S.B.F.), and the Section of Pediatric Emergency Medicine, Alberta Children's Hospital (S.W.-U., J.X.), Cumming School of Medicine, University of Calgary, Calgary, the Departments of Pediatrics and Emergency Medicine, Children's Hospital of Eastern Ontario, University of Ottawa, Ottawa (K.J.F.), the Division of Pediatric Emergency Medicine, Department of Pediatrics, Centre Hospitalier Universitaire Sainte-Justine, Université de Montréal, Montreal (S.G.), Ontario Child Health Support Unit, SickKids Research Institute, the Division of Biostatistics, Dalla Lana School of Public Health (A.R.W.), the Division of Gastroenterology, Hepatology, and Nutrition (P.M.S.), the Divisions of Pediatric Emergency Medicine and Clinical Pharmacology and Toxicology (Y.F.), and the Division of Pediatric Emergency Medicine and Research Institute (S.S.), Hospital for Sick Children, University of Toronto, Toronto, the Division of Emergency Medicine, London Health Sciences Centre, Department of Pediatrics, Schulich School of Medicine and Dentistry, Western University, London, ON (N.P.), the Division of Pediatric Emergency Medicine, IWK Health Centre, Halifax, NS (K.H.), the Department of Pediatrics, Faculty of Medicine and Dentistry, Women and Children's Health Research Institute (B.E.L.) and the Provincial Laboratory for Public Health-Alberta Public Laboratories and Department of Laboratory Medicine and Pathology (X.-L.P., L.C.), University of Alberta, Edmonton - all in Canada; the Division of Pediatric Emergency Medicine, Washington University School of Medicine, St. Louis (D.S.); and Children's Minnesota and Department of Pediatrics, University of Minnesota Medical School, Minneapolis (M.G.)
| | - Suzanne Schuh
- From the Sections of Pediatric Emergency Medicine and Gastroenterology, Alberta Children's Hospital, Alberta Children's Hospital Research Institute (S.B.F.), and the Section of Pediatric Emergency Medicine, Alberta Children's Hospital (S.W.-U., J.X.), Cumming School of Medicine, University of Calgary, Calgary, the Departments of Pediatrics and Emergency Medicine, Children's Hospital of Eastern Ontario, University of Ottawa, Ottawa (K.J.F.), the Division of Pediatric Emergency Medicine, Department of Pediatrics, Centre Hospitalier Universitaire Sainte-Justine, Université de Montréal, Montreal (S.G.), Ontario Child Health Support Unit, SickKids Research Institute, the Division of Biostatistics, Dalla Lana School of Public Health (A.R.W.), the Division of Gastroenterology, Hepatology, and Nutrition (P.M.S.), the Divisions of Pediatric Emergency Medicine and Clinical Pharmacology and Toxicology (Y.F.), and the Division of Pediatric Emergency Medicine and Research Institute (S.S.), Hospital for Sick Children, University of Toronto, Toronto, the Division of Emergency Medicine, London Health Sciences Centre, Department of Pediatrics, Schulich School of Medicine and Dentistry, Western University, London, ON (N.P.), the Division of Pediatric Emergency Medicine, IWK Health Centre, Halifax, NS (K.H.), the Department of Pediatrics, Faculty of Medicine and Dentistry, Women and Children's Health Research Institute (B.E.L.) and the Provincial Laboratory for Public Health-Alberta Public Laboratories and Department of Laboratory Medicine and Pathology (X.-L.P., L.C.), University of Alberta, Edmonton - all in Canada; the Division of Pediatric Emergency Medicine, Washington University School of Medicine, St. Louis (D.S.); and Children's Minnesota and Department of Pediatrics, University of Minnesota Medical School, Minneapolis (M.G.)
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Hutton EK, Hannah ME, Willan AR, Ross S, Allen AC, Armson BA, Gafni A, Joseph KS, Mangoff K, Ohlsson A, Sanchez JJ, Asztalos EV, Barrett J. Urinary stress incontinence and other maternal outcomes 2 years after caesarean or vaginal birth for twin pregnancy: a multicentre randomised trial. BJOG 2018; 125:1682-1690. [PMID: 30007113 PMCID: PMC6282843 DOI: 10.1111/1471-0528.15407] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/22/2018] [Indexed: 11/30/2022]
Abstract
OBJECTIVE Does planned caesarean compared with planned vaginal birth lower the risk of problematic urinary stress, faecal, or flatal incontinence? DESIGN Women between 320/7 and 386/7 weeks of gestation with a twin pregnancy were randomised to planned caesarean or planned vaginal birth. SETTING The trial took place at 106 centres in 25 countries. POPULATION A total of 2305 of the 2804 women enrolled in the study completed questionnaires at 2 years (82.2% follow-up): 1155 in the planned caesarean group and 1150 in the planned vaginal birth group. METHODS A structured self-administered questionnaire completed at 2 years postpartum. MAIN OUTCOME MEASURES The primary maternal outcome of the Twin Birth Study was problematic urinary stress, or fecal, or flatal incontinence at 2 years RESULTS: Women in the planned caesarean group had lower problematic urinary stress incontinence rates compared with women in the planned vaginal birth group [93/1147 (8.11%) versus 140/1143 (12.25%); odds ratio, 0.63; 95% confidence interval, 0.47-0.83; P = 0.001]. Among those with problematic urinary stress incontinence, quality of life (measured using the Incontinence Impact Questionnaire, IIQ-7) was not different for planned caesarean versus planned vaginal birth groups [mean (SD): 18.4 (21.0) versus 19.1 (21.5); P = 0.82]. There were no differences in problematic faecal or flatal incontinence, or in other maternal outcomes. CONCLUSIONS Among women with a twin pregnancy and no prior history of urinary stress incontinence, a management strategy of planned caesarean compared with planned vaginal birth reduces the risk of problematic urinary stress incontinence at 2 years postpartum. Our findings show that the prevalence but not the severity of urinary stress incontinence was associated with mode of birth. FUNDING Canadian Institutes of Health Research (CIHR) (grant no. MCT-63164). TWEETABLE ABSTRACT For women with twins, planned caesarean compared with planned vaginal birth is associated with decreased prevalence but not severity of urinary stress incontinence at 2 years.
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Affiliation(s)
- E K Hutton
- Division of Midwifery, Department of Obstetrics and Gynecology, McMaster University, Hamilton, ON, Canada
| | - M E Hannah
- Department of Obstetrics and Gynaecology, University of Toronto, Toronto, ON, Canada
| | - A R Willan
- Program in Child Health Evaluative Sciences, Sick Kids Research Institute, Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada
| | - S Ross
- Department of Obstetrics and Gynaecology, University of Alberta, Edmonton, AB, Canada
| | - A C Allen
- Department of Paediatrics, IWK Health Centre, Dalhousie University, Halifax, NS, Canada
| | - B A Armson
- Department of Obstetrics and Gynaecology, IWK Health Centre, Dalhousie University, Halifax, NS, Canada
| | - A Gafni
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
| | - K S Joseph
- Department of Obstetrics and Gynaecology, School of Population and Public Health, University of British Columbia, Vancouver, BC, Canada
| | - K Mangoff
- The Centre for Mother, Infant, and Child Research, Sunnybrook Research Institute, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON, Canada
| | - A Ohlsson
- Department of Paediatrics, Mount Sinai Hospital, University of Toronto, Toronto, ON, Canada
| | - J J Sanchez
- The Centre for Mother, Infant, and Child Research, Sunnybrook Research Institute, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON, Canada
| | - E V Asztalos
- Department of Newborn & Developmental Paediatrics, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON, Canada
| | - Jfr Barrett
- Department of Obstetrics and Gynaecology, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON, Canada
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Roth DE, Morris SK, Zlotkin S, Gernand AD, Ahmed T, Shanta SS, Papp E, Korsiak J, Shi J, Islam MM, Jahan I, Keya FK, Willan AR, Weksberg R, Mohsin M, Rahman QS, Shah PS, Murphy KE, Stimec J, Pell LG, Qamar H, Al Mahmud A. Vitamin D Supplementation in Pregnancy and Lactation and Infant Growth. N Engl J Med 2018; 379:535-546. [PMID: 30089075 PMCID: PMC6004541 DOI: 10.1056/nejmoa1800927] [Citation(s) in RCA: 119] [Impact Index Per Article: 19.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
BACKGROUND It is unclear whether maternal vitamin D supplementation during pregnancy and lactation improves fetal and infant growth in regions where vitamin D deficiency is common. METHODS We conducted a randomized, double-blind, placebo-controlled trial in Bangladesh to assess the effects of weekly prenatal vitamin D supplementation (from 17 to 24 weeks of gestation until birth) and postpartum vitamin D supplementation on the primary outcome of infants' length-for-age z scores at 1 year according to World Health Organization (WHO) child growth standards. One group received neither prenatal nor postpartum vitamin D (placebo group). Three groups received prenatal supplementation only, in doses of 4200 IU (prenatal 4200 group), 16,800 IU (prenatal 16,800 group), and 28,000 IU (prenatal 28,000 group). The fifth group received prenatal supplementation as well as 26 weeks of postpartum supplementation in the amount of 28,000 IU (prenatal and postpartum 28,000 group). RESULTS Among 1164 infants assessed at 1 year of age (89.5% of 1300 pregnancies), there were no significant differences across groups in the mean (±SD) length-for-age z scores. Scores were as follows: placebo, -0.93±1.05; prenatal 4200, -1.11±1.12; prenatal 16,800, -0.97±0.97; prenatal 28,000, -1.06±1.07; and prenatal and postpartum 28,000, -0.94±1.00 (P=0.23 for a global test of differences across groups). Other anthropometric measures, birth outcomes, and morbidity did not differ significantly across groups. Vitamin D supplementation had expected effects on maternal and infant serum 25-hydroxyvitamin D and calcium concentrations, maternal urinary calcium excretion, and maternal parathyroid hormone concentrations. There were no significant differences in the frequencies of adverse events across groups, with the exception of a higher rate of possible hypercalciuria among the women receiving the highest dose. CONCLUSIONS In a population with widespread prenatal vitamin D deficiency and fetal and infant growth restriction, maternal vitamin D supplementation from midpregnancy until birth or until 6 months post partum did not improve fetal or infant growth. (Funded by the Bill and Melinda Gates Foundation; ClinicalTrials.gov number, NCT01924013 .).
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Affiliation(s)
- Daniel E Roth
- From the Department of Pediatrics (D.E.R., S.K.M., S.Z., E.P., J.K., J. Shi, R.W., P.S.S., L.G.P., H.Q.) and the Dalla Lana School of Public Health (A.R.W.), University of Toronto, and the Centre for Global Child Health (D.E.R., S.K.M., S.Z., E.P., J.K., J. Shi, R.W., L.G.P., H.Q.), the Department of Diagnostic Imaging (J. Stimec), and the Ontario Child Health Support Unit (A.R.W.), Hospital for Sick Children, and the Departments of Pediatrics (P.S.S.), and Obstetrics and Gynecology (K.E.M.), Mt. Sinai Hospital - all in Toronto; the Department of Nutritional Sciences, Penn State University, University Park, PA (A.D.G.); and the Maternal and Child Health Training Institute (I.J.) and the Nutrition and Clinical Services Division, International Center for Diarrheal Disease Research, Bangladesh (T.A., S.S.S., M.M.I., F.K.K., M.M., Q.S.R., A.A.M.), Dhaka, Bangladesh
| | - Shaun K Morris
- From the Department of Pediatrics (D.E.R., S.K.M., S.Z., E.P., J.K., J. Shi, R.W., P.S.S., L.G.P., H.Q.) and the Dalla Lana School of Public Health (A.R.W.), University of Toronto, and the Centre for Global Child Health (D.E.R., S.K.M., S.Z., E.P., J.K., J. Shi, R.W., L.G.P., H.Q.), the Department of Diagnostic Imaging (J. Stimec), and the Ontario Child Health Support Unit (A.R.W.), Hospital for Sick Children, and the Departments of Pediatrics (P.S.S.), and Obstetrics and Gynecology (K.E.M.), Mt. Sinai Hospital - all in Toronto; the Department of Nutritional Sciences, Penn State University, University Park, PA (A.D.G.); and the Maternal and Child Health Training Institute (I.J.) and the Nutrition and Clinical Services Division, International Center for Diarrheal Disease Research, Bangladesh (T.A., S.S.S., M.M.I., F.K.K., M.M., Q.S.R., A.A.M.), Dhaka, Bangladesh
| | - Stanley Zlotkin
- From the Department of Pediatrics (D.E.R., S.K.M., S.Z., E.P., J.K., J. Shi, R.W., P.S.S., L.G.P., H.Q.) and the Dalla Lana School of Public Health (A.R.W.), University of Toronto, and the Centre for Global Child Health (D.E.R., S.K.M., S.Z., E.P., J.K., J. Shi, R.W., L.G.P., H.Q.), the Department of Diagnostic Imaging (J. Stimec), and the Ontario Child Health Support Unit (A.R.W.), Hospital for Sick Children, and the Departments of Pediatrics (P.S.S.), and Obstetrics and Gynecology (K.E.M.), Mt. Sinai Hospital - all in Toronto; the Department of Nutritional Sciences, Penn State University, University Park, PA (A.D.G.); and the Maternal and Child Health Training Institute (I.J.) and the Nutrition and Clinical Services Division, International Center for Diarrheal Disease Research, Bangladesh (T.A., S.S.S., M.M.I., F.K.K., M.M., Q.S.R., A.A.M.), Dhaka, Bangladesh
| | - Alison D Gernand
- From the Department of Pediatrics (D.E.R., S.K.M., S.Z., E.P., J.K., J. Shi, R.W., P.S.S., L.G.P., H.Q.) and the Dalla Lana School of Public Health (A.R.W.), University of Toronto, and the Centre for Global Child Health (D.E.R., S.K.M., S.Z., E.P., J.K., J. Shi, R.W., L.G.P., H.Q.), the Department of Diagnostic Imaging (J. Stimec), and the Ontario Child Health Support Unit (A.R.W.), Hospital for Sick Children, and the Departments of Pediatrics (P.S.S.), and Obstetrics and Gynecology (K.E.M.), Mt. Sinai Hospital - all in Toronto; the Department of Nutritional Sciences, Penn State University, University Park, PA (A.D.G.); and the Maternal and Child Health Training Institute (I.J.) and the Nutrition and Clinical Services Division, International Center for Diarrheal Disease Research, Bangladesh (T.A., S.S.S., M.M.I., F.K.K., M.M., Q.S.R., A.A.M.), Dhaka, Bangladesh
| | - Tahmeed Ahmed
- From the Department of Pediatrics (D.E.R., S.K.M., S.Z., E.P., J.K., J. Shi, R.W., P.S.S., L.G.P., H.Q.) and the Dalla Lana School of Public Health (A.R.W.), University of Toronto, and the Centre for Global Child Health (D.E.R., S.K.M., S.Z., E.P., J.K., J. Shi, R.W., L.G.P., H.Q.), the Department of Diagnostic Imaging (J. Stimec), and the Ontario Child Health Support Unit (A.R.W.), Hospital for Sick Children, and the Departments of Pediatrics (P.S.S.), and Obstetrics and Gynecology (K.E.M.), Mt. Sinai Hospital - all in Toronto; the Department of Nutritional Sciences, Penn State University, University Park, PA (A.D.G.); and the Maternal and Child Health Training Institute (I.J.) and the Nutrition and Clinical Services Division, International Center for Diarrheal Disease Research, Bangladesh (T.A., S.S.S., M.M.I., F.K.K., M.M., Q.S.R., A.A.M.), Dhaka, Bangladesh
| | - Shaila S Shanta
- From the Department of Pediatrics (D.E.R., S.K.M., S.Z., E.P., J.K., J. Shi, R.W., P.S.S., L.G.P., H.Q.) and the Dalla Lana School of Public Health (A.R.W.), University of Toronto, and the Centre for Global Child Health (D.E.R., S.K.M., S.Z., E.P., J.K., J. Shi, R.W., L.G.P., H.Q.), the Department of Diagnostic Imaging (J. Stimec), and the Ontario Child Health Support Unit (A.R.W.), Hospital for Sick Children, and the Departments of Pediatrics (P.S.S.), and Obstetrics and Gynecology (K.E.M.), Mt. Sinai Hospital - all in Toronto; the Department of Nutritional Sciences, Penn State University, University Park, PA (A.D.G.); and the Maternal and Child Health Training Institute (I.J.) and the Nutrition and Clinical Services Division, International Center for Diarrheal Disease Research, Bangladesh (T.A., S.S.S., M.M.I., F.K.K., M.M., Q.S.R., A.A.M.), Dhaka, Bangladesh
| | - Eszter Papp
- From the Department of Pediatrics (D.E.R., S.K.M., S.Z., E.P., J.K., J. Shi, R.W., P.S.S., L.G.P., H.Q.) and the Dalla Lana School of Public Health (A.R.W.), University of Toronto, and the Centre for Global Child Health (D.E.R., S.K.M., S.Z., E.P., J.K., J. Shi, R.W., L.G.P., H.Q.), the Department of Diagnostic Imaging (J. Stimec), and the Ontario Child Health Support Unit (A.R.W.), Hospital for Sick Children, and the Departments of Pediatrics (P.S.S.), and Obstetrics and Gynecology (K.E.M.), Mt. Sinai Hospital - all in Toronto; the Department of Nutritional Sciences, Penn State University, University Park, PA (A.D.G.); and the Maternal and Child Health Training Institute (I.J.) and the Nutrition and Clinical Services Division, International Center for Diarrheal Disease Research, Bangladesh (T.A., S.S.S., M.M.I., F.K.K., M.M., Q.S.R., A.A.M.), Dhaka, Bangladesh
| | - Jill Korsiak
- From the Department of Pediatrics (D.E.R., S.K.M., S.Z., E.P., J.K., J. Shi, R.W., P.S.S., L.G.P., H.Q.) and the Dalla Lana School of Public Health (A.R.W.), University of Toronto, and the Centre for Global Child Health (D.E.R., S.K.M., S.Z., E.P., J.K., J. Shi, R.W., L.G.P., H.Q.), the Department of Diagnostic Imaging (J. Stimec), and the Ontario Child Health Support Unit (A.R.W.), Hospital for Sick Children, and the Departments of Pediatrics (P.S.S.), and Obstetrics and Gynecology (K.E.M.), Mt. Sinai Hospital - all in Toronto; the Department of Nutritional Sciences, Penn State University, University Park, PA (A.D.G.); and the Maternal and Child Health Training Institute (I.J.) and the Nutrition and Clinical Services Division, International Center for Diarrheal Disease Research, Bangladesh (T.A., S.S.S., M.M.I., F.K.K., M.M., Q.S.R., A.A.M.), Dhaka, Bangladesh
| | - Joy Shi
- From the Department of Pediatrics (D.E.R., S.K.M., S.Z., E.P., J.K., J. Shi, R.W., P.S.S., L.G.P., H.Q.) and the Dalla Lana School of Public Health (A.R.W.), University of Toronto, and the Centre for Global Child Health (D.E.R., S.K.M., S.Z., E.P., J.K., J. Shi, R.W., L.G.P., H.Q.), the Department of Diagnostic Imaging (J. Stimec), and the Ontario Child Health Support Unit (A.R.W.), Hospital for Sick Children, and the Departments of Pediatrics (P.S.S.), and Obstetrics and Gynecology (K.E.M.), Mt. Sinai Hospital - all in Toronto; the Department of Nutritional Sciences, Penn State University, University Park, PA (A.D.G.); and the Maternal and Child Health Training Institute (I.J.) and the Nutrition and Clinical Services Division, International Center for Diarrheal Disease Research, Bangladesh (T.A., S.S.S., M.M.I., F.K.K., M.M., Q.S.R., A.A.M.), Dhaka, Bangladesh
| | - M Munirul Islam
- From the Department of Pediatrics (D.E.R., S.K.M., S.Z., E.P., J.K., J. Shi, R.W., P.S.S., L.G.P., H.Q.) and the Dalla Lana School of Public Health (A.R.W.), University of Toronto, and the Centre for Global Child Health (D.E.R., S.K.M., S.Z., E.P., J.K., J. Shi, R.W., L.G.P., H.Q.), the Department of Diagnostic Imaging (J. Stimec), and the Ontario Child Health Support Unit (A.R.W.), Hospital for Sick Children, and the Departments of Pediatrics (P.S.S.), and Obstetrics and Gynecology (K.E.M.), Mt. Sinai Hospital - all in Toronto; the Department of Nutritional Sciences, Penn State University, University Park, PA (A.D.G.); and the Maternal and Child Health Training Institute (I.J.) and the Nutrition and Clinical Services Division, International Center for Diarrheal Disease Research, Bangladesh (T.A., S.S.S., M.M.I., F.K.K., M.M., Q.S.R., A.A.M.), Dhaka, Bangladesh
| | - Ishrat Jahan
- From the Department of Pediatrics (D.E.R., S.K.M., S.Z., E.P., J.K., J. Shi, R.W., P.S.S., L.G.P., H.Q.) and the Dalla Lana School of Public Health (A.R.W.), University of Toronto, and the Centre for Global Child Health (D.E.R., S.K.M., S.Z., E.P., J.K., J. Shi, R.W., L.G.P., H.Q.), the Department of Diagnostic Imaging (J. Stimec), and the Ontario Child Health Support Unit (A.R.W.), Hospital for Sick Children, and the Departments of Pediatrics (P.S.S.), and Obstetrics and Gynecology (K.E.M.), Mt. Sinai Hospital - all in Toronto; the Department of Nutritional Sciences, Penn State University, University Park, PA (A.D.G.); and the Maternal and Child Health Training Institute (I.J.) and the Nutrition and Clinical Services Division, International Center for Diarrheal Disease Research, Bangladesh (T.A., S.S.S., M.M.I., F.K.K., M.M., Q.S.R., A.A.M.), Dhaka, Bangladesh
| | - Farhana K Keya
- From the Department of Pediatrics (D.E.R., S.K.M., S.Z., E.P., J.K., J. Shi, R.W., P.S.S., L.G.P., H.Q.) and the Dalla Lana School of Public Health (A.R.W.), University of Toronto, and the Centre for Global Child Health (D.E.R., S.K.M., S.Z., E.P., J.K., J. Shi, R.W., L.G.P., H.Q.), the Department of Diagnostic Imaging (J. Stimec), and the Ontario Child Health Support Unit (A.R.W.), Hospital for Sick Children, and the Departments of Pediatrics (P.S.S.), and Obstetrics and Gynecology (K.E.M.), Mt. Sinai Hospital - all in Toronto; the Department of Nutritional Sciences, Penn State University, University Park, PA (A.D.G.); and the Maternal and Child Health Training Institute (I.J.) and the Nutrition and Clinical Services Division, International Center for Diarrheal Disease Research, Bangladesh (T.A., S.S.S., M.M.I., F.K.K., M.M., Q.S.R., A.A.M.), Dhaka, Bangladesh
| | - Andrew R Willan
- From the Department of Pediatrics (D.E.R., S.K.M., S.Z., E.P., J.K., J. Shi, R.W., P.S.S., L.G.P., H.Q.) and the Dalla Lana School of Public Health (A.R.W.), University of Toronto, and the Centre for Global Child Health (D.E.R., S.K.M., S.Z., E.P., J.K., J. Shi, R.W., L.G.P., H.Q.), the Department of Diagnostic Imaging (J. Stimec), and the Ontario Child Health Support Unit (A.R.W.), Hospital for Sick Children, and the Departments of Pediatrics (P.S.S.), and Obstetrics and Gynecology (K.E.M.), Mt. Sinai Hospital - all in Toronto; the Department of Nutritional Sciences, Penn State University, University Park, PA (A.D.G.); and the Maternal and Child Health Training Institute (I.J.) and the Nutrition and Clinical Services Division, International Center for Diarrheal Disease Research, Bangladesh (T.A., S.S.S., M.M.I., F.K.K., M.M., Q.S.R., A.A.M.), Dhaka, Bangladesh
| | - Rosanna Weksberg
- From the Department of Pediatrics (D.E.R., S.K.M., S.Z., E.P., J.K., J. Shi, R.W., P.S.S., L.G.P., H.Q.) and the Dalla Lana School of Public Health (A.R.W.), University of Toronto, and the Centre for Global Child Health (D.E.R., S.K.M., S.Z., E.P., J.K., J. Shi, R.W., L.G.P., H.Q.), the Department of Diagnostic Imaging (J. Stimec), and the Ontario Child Health Support Unit (A.R.W.), Hospital for Sick Children, and the Departments of Pediatrics (P.S.S.), and Obstetrics and Gynecology (K.E.M.), Mt. Sinai Hospital - all in Toronto; the Department of Nutritional Sciences, Penn State University, University Park, PA (A.D.G.); and the Maternal and Child Health Training Institute (I.J.) and the Nutrition and Clinical Services Division, International Center for Diarrheal Disease Research, Bangladesh (T.A., S.S.S., M.M.I., F.K.K., M.M., Q.S.R., A.A.M.), Dhaka, Bangladesh
| | - Minhazul Mohsin
- From the Department of Pediatrics (D.E.R., S.K.M., S.Z., E.P., J.K., J. Shi, R.W., P.S.S., L.G.P., H.Q.) and the Dalla Lana School of Public Health (A.R.W.), University of Toronto, and the Centre for Global Child Health (D.E.R., S.K.M., S.Z., E.P., J.K., J. Shi, R.W., L.G.P., H.Q.), the Department of Diagnostic Imaging (J. Stimec), and the Ontario Child Health Support Unit (A.R.W.), Hospital for Sick Children, and the Departments of Pediatrics (P.S.S.), and Obstetrics and Gynecology (K.E.M.), Mt. Sinai Hospital - all in Toronto; the Department of Nutritional Sciences, Penn State University, University Park, PA (A.D.G.); and the Maternal and Child Health Training Institute (I.J.) and the Nutrition and Clinical Services Division, International Center for Diarrheal Disease Research, Bangladesh (T.A., S.S.S., M.M.I., F.K.K., M.M., Q.S.R., A.A.M.), Dhaka, Bangladesh
| | - Qazi S Rahman
- From the Department of Pediatrics (D.E.R., S.K.M., S.Z., E.P., J.K., J. Shi, R.W., P.S.S., L.G.P., H.Q.) and the Dalla Lana School of Public Health (A.R.W.), University of Toronto, and the Centre for Global Child Health (D.E.R., S.K.M., S.Z., E.P., J.K., J. Shi, R.W., L.G.P., H.Q.), the Department of Diagnostic Imaging (J. Stimec), and the Ontario Child Health Support Unit (A.R.W.), Hospital for Sick Children, and the Departments of Pediatrics (P.S.S.), and Obstetrics and Gynecology (K.E.M.), Mt. Sinai Hospital - all in Toronto; the Department of Nutritional Sciences, Penn State University, University Park, PA (A.D.G.); and the Maternal and Child Health Training Institute (I.J.) and the Nutrition and Clinical Services Division, International Center for Diarrheal Disease Research, Bangladesh (T.A., S.S.S., M.M.I., F.K.K., M.M., Q.S.R., A.A.M.), Dhaka, Bangladesh
| | - Prakesh S Shah
- From the Department of Pediatrics (D.E.R., S.K.M., S.Z., E.P., J.K., J. Shi, R.W., P.S.S., L.G.P., H.Q.) and the Dalla Lana School of Public Health (A.R.W.), University of Toronto, and the Centre for Global Child Health (D.E.R., S.K.M., S.Z., E.P., J.K., J. Shi, R.W., L.G.P., H.Q.), the Department of Diagnostic Imaging (J. Stimec), and the Ontario Child Health Support Unit (A.R.W.), Hospital for Sick Children, and the Departments of Pediatrics (P.S.S.), and Obstetrics and Gynecology (K.E.M.), Mt. Sinai Hospital - all in Toronto; the Department of Nutritional Sciences, Penn State University, University Park, PA (A.D.G.); and the Maternal and Child Health Training Institute (I.J.) and the Nutrition and Clinical Services Division, International Center for Diarrheal Disease Research, Bangladesh (T.A., S.S.S., M.M.I., F.K.K., M.M., Q.S.R., A.A.M.), Dhaka, Bangladesh
| | - Kellie E Murphy
- From the Department of Pediatrics (D.E.R., S.K.M., S.Z., E.P., J.K., J. Shi, R.W., P.S.S., L.G.P., H.Q.) and the Dalla Lana School of Public Health (A.R.W.), University of Toronto, and the Centre for Global Child Health (D.E.R., S.K.M., S.Z., E.P., J.K., J. Shi, R.W., L.G.P., H.Q.), the Department of Diagnostic Imaging (J. Stimec), and the Ontario Child Health Support Unit (A.R.W.), Hospital for Sick Children, and the Departments of Pediatrics (P.S.S.), and Obstetrics and Gynecology (K.E.M.), Mt. Sinai Hospital - all in Toronto; the Department of Nutritional Sciences, Penn State University, University Park, PA (A.D.G.); and the Maternal and Child Health Training Institute (I.J.) and the Nutrition and Clinical Services Division, International Center for Diarrheal Disease Research, Bangladesh (T.A., S.S.S., M.M.I., F.K.K., M.M., Q.S.R., A.A.M.), Dhaka, Bangladesh
| | - Jennifer Stimec
- From the Department of Pediatrics (D.E.R., S.K.M., S.Z., E.P., J.K., J. Shi, R.W., P.S.S., L.G.P., H.Q.) and the Dalla Lana School of Public Health (A.R.W.), University of Toronto, and the Centre for Global Child Health (D.E.R., S.K.M., S.Z., E.P., J.K., J. Shi, R.W., L.G.P., H.Q.), the Department of Diagnostic Imaging (J. Stimec), and the Ontario Child Health Support Unit (A.R.W.), Hospital for Sick Children, and the Departments of Pediatrics (P.S.S.), and Obstetrics and Gynecology (K.E.M.), Mt. Sinai Hospital - all in Toronto; the Department of Nutritional Sciences, Penn State University, University Park, PA (A.D.G.); and the Maternal and Child Health Training Institute (I.J.) and the Nutrition and Clinical Services Division, International Center for Diarrheal Disease Research, Bangladesh (T.A., S.S.S., M.M.I., F.K.K., M.M., Q.S.R., A.A.M.), Dhaka, Bangladesh
| | - Lisa G Pell
- From the Department of Pediatrics (D.E.R., S.K.M., S.Z., E.P., J.K., J. Shi, R.W., P.S.S., L.G.P., H.Q.) and the Dalla Lana School of Public Health (A.R.W.), University of Toronto, and the Centre for Global Child Health (D.E.R., S.K.M., S.Z., E.P., J.K., J. Shi, R.W., L.G.P., H.Q.), the Department of Diagnostic Imaging (J. Stimec), and the Ontario Child Health Support Unit (A.R.W.), Hospital for Sick Children, and the Departments of Pediatrics (P.S.S.), and Obstetrics and Gynecology (K.E.M.), Mt. Sinai Hospital - all in Toronto; the Department of Nutritional Sciences, Penn State University, University Park, PA (A.D.G.); and the Maternal and Child Health Training Institute (I.J.) and the Nutrition and Clinical Services Division, International Center for Diarrheal Disease Research, Bangladesh (T.A., S.S.S., M.M.I., F.K.K., M.M., Q.S.R., A.A.M.), Dhaka, Bangladesh
| | - Huma Qamar
- From the Department of Pediatrics (D.E.R., S.K.M., S.Z., E.P., J.K., J. Shi, R.W., P.S.S., L.G.P., H.Q.) and the Dalla Lana School of Public Health (A.R.W.), University of Toronto, and the Centre for Global Child Health (D.E.R., S.K.M., S.Z., E.P., J.K., J. Shi, R.W., L.G.P., H.Q.), the Department of Diagnostic Imaging (J. Stimec), and the Ontario Child Health Support Unit (A.R.W.), Hospital for Sick Children, and the Departments of Pediatrics (P.S.S.), and Obstetrics and Gynecology (K.E.M.), Mt. Sinai Hospital - all in Toronto; the Department of Nutritional Sciences, Penn State University, University Park, PA (A.D.G.); and the Maternal and Child Health Training Institute (I.J.) and the Nutrition and Clinical Services Division, International Center for Diarrheal Disease Research, Bangladesh (T.A., S.S.S., M.M.I., F.K.K., M.M., Q.S.R., A.A.M.), Dhaka, Bangladesh
| | - Abdullah Al Mahmud
- From the Department of Pediatrics (D.E.R., S.K.M., S.Z., E.P., J.K., J. Shi, R.W., P.S.S., L.G.P., H.Q.) and the Dalla Lana School of Public Health (A.R.W.), University of Toronto, and the Centre for Global Child Health (D.E.R., S.K.M., S.Z., E.P., J.K., J. Shi, R.W., L.G.P., H.Q.), the Department of Diagnostic Imaging (J. Stimec), and the Ontario Child Health Support Unit (A.R.W.), Hospital for Sick Children, and the Departments of Pediatrics (P.S.S.), and Obstetrics and Gynecology (K.E.M.), Mt. Sinai Hospital - all in Toronto; the Department of Nutritional Sciences, Penn State University, University Park, PA (A.D.G.); and the Maternal and Child Health Training Institute (I.J.) and the Nutrition and Clinical Services Division, International Center for Diarrheal Disease Research, Bangladesh (T.A., S.S.S., M.M.I., F.K.K., M.M., Q.S.R., A.A.M.), Dhaka, Bangladesh
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Mahant S, Wahi G, Giglia L, Pound C, Kanani R, Bayliss A, Roy M, Sakran M, Kozlowski N, Breen-Reid K, Lavigne M, Premji L, Moretti ME, Willan AR, Schuh S, Parkin PC. Intermittent versus continuous oxygen saturation monitoring for infants hospitalised with bronchiolitis: study protocol for a pragmatic randomised controlled trial. BMJ Open 2018; 8:e022707. [PMID: 29678995 PMCID: PMC5914772 DOI: 10.1136/bmjopen-2018-022707] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
INTRODUCTION Bronchiolitis is the most common reason for hospitalisation in infants in developed countries. The main focus of hospital care is on supportive care, such as monitoring for hypoxia and supplemental oxygen administration, as active therapies lack effectiveness. Pulse oximetry is used to monitor hypoxia in hospitalised infants and is used either intermittently or continuously. Observational studies have suggested that continuous pulse oximetry use leads to a longer length of hospital stay in stable infants. The use of continuous pulse oximetry may lead to unnecessary clinical intervention due to readings that are of little clinical significance, false-positive readings and less reliance on the clinical status. There is a lack of high-quality evidence to guide which pulse oximetry monitoring strategy, intermittent or continuous, is superior in infants hospitalised with bronchiolitis with respect to patient and policy-relevant outcomes. METHODS AND ANALYSIS This is a multicentre, pragmatic randomised controlled trial comparing two strategies for pulse oximetry monitoring in infants hospitalised for bronchiolitis. Infants aged 1 month to 2 years presenting to Canadian tertiary and community hospitals will be randomised after stabilisation to receive either intermittent or continuous oxygen saturation monitoring on the inpatient unit until discharge. The primary outcome is length of hospital stay. Secondary outcomes include additional measures of effectiveness, acceptability, safety and cost. We will need to enrol 210 infants in order to detect a 12-hour difference in length of stay with a type 1 error rate of 5% and a power of 90%. ETHICS AND DISSEMINATION Research ethics approval has been obtained for this trial. This trial will provide data to guide hospitals and clinicians on the optimal pulse oximetry monitoring strategy in infants hospitalised with bronchiolitis. We will disseminate the findings of this study through peer-reviewed publication, professional societies and meetings. TRIAL REGISTRATION NUMBER NCT02947204.
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Affiliation(s)
- Sanjay Mahant
- Division of Paediatric Medicine, Paediatric Outcomes Research Team (PORT), Department of Paediatrics and Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
- Research Institute, Hospital for Sick Children, Hamilton, Ontario, Canada
| | - Gita Wahi
- Department of Pediatrics, Hamilton Health Sciences Centre, McMaster University, Hamilton, Ontario, Canada
| | - Lucy Giglia
- Department of Pediatrics, Hamilton Health Sciences Centre, McMaster University, Hamilton, Ontario, Canada
| | - Catherine Pound
- Department of Paediatrics, Children’s Hospital of Eastern Ontario, University of Ottawa, Ottawa, Ontario, Canada
| | - Ronik Kanani
- Department of Paediatrics, North York General Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Ann Bayliss
- Trillium Health Partners, Department of Paediatrics, University of Toronto, Mississauga, Ontario, Canada
| | - Madan Roy
- Department of Pediatrics, Hamilton Health Sciences Centre, McMaster University, Hamilton, Ontario, Canada
| | - Mahmoud Sakran
- Department of Paediatrics, Queens University, Lakeridge Health, Oshawa, Ontario, Canada
| | | | - Karen Breen-Reid
- Interprofessional Education, Learning Institute, Hospital for Sick Children, Toronto, Ontario, Canada
- Lawrence Bloomberg Faculty of Nursing, University of Toronto, Toronto, Ontario, Canada
| | - Mollie Lavigne
- Lawrence Bloomberg Faculty of Nursing, University of Toronto, Toronto, Ontario, Canada
| | - Laila Premji
- Division of Paediatric Medicine, Hospital for Sick Children, Toronto, Ontario, Canada
| | - Myla E Moretti
- Clinical Trials Unit-Ontario Child Health Support Unit, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Andrew R Willan
- Dalla Lana School of Public Health, Ontario Child Health Support Unit, Research Institute, Hospital for Sick Children, Toronto, Ontario, Canada
| | - Suzanne Schuh
- Division of Emergency Medicine, Department of Paediatrics, University of Toronto Research Institute, Hospital for Sick Children, Toronto, Ontario, Canada
| | - Patricia C Parkin
- Division of Paediatric Medicine, Paediatric Outcomes Research Team (PORT), Department of Paediatrics and Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
- Research Institute, Hospital for Sick Children, Hamilton, Ontario, Canada
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Parshuram CS, Dryden-Palmer K, Farrell C, Gottesman R, Gray M, Hutchison JS, Helfaer M, Hunt EA, Joffe AR, Lacroix J, Moga MA, Nadkarni V, Ninis N, Parkin PC, Wensley D, Willan AR, Tomlinson GA. Effect of a Pediatric Early Warning System on All-Cause Mortality in Hospitalized Pediatric Patients: The EPOCH Randomized Clinical Trial. JAMA 2018; 319:1002-1012. [PMID: 29486493 PMCID: PMC5885881 DOI: 10.1001/jama.2018.0948] [Citation(s) in RCA: 128] [Impact Index Per Article: 21.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
IMPORTANCE There is limited evidence that the use of severity of illness scores in pediatric patients can facilitate timely admission to the intensive care unit or improve patient outcomes. OBJECTIVE To determine the effect of the Bedside Paediatric Early Warning System (BedsidePEWS) on all-cause hospital mortality and late admission to the intensive care unit (ICU), cardiac arrest, and ICU resource use. DESIGN, SETTING, AND PARTICIPANTS A multicenter cluster randomized trial of 21 hospitals located in 7 countries (Belgium, Canada, England, Ireland, Italy, New Zealand, and the Netherlands) that provided inpatient pediatric care for infants (gestational age ≥37 weeks) to teenagers (aged ≤18 years). Participating hospitals had continuous physician staffing and subspecialized pediatric services. Patient enrollment began on February 28, 2011, and ended on June 21, 2015. Follow-up ended on July 19, 2015. INTERVENTIONS The BedsidePEWS intervention (10 hospitals) was compared with usual care (no severity of illness score; 11 hospitals). MAIN OUTCOMES AND MEASURES The primary outcome was all-cause hospital mortality. The secondary outcome was a significant clinical deterioration event, which was defined as a composite outcome reflecting late ICU admission. Regression analyses accounted for hospital-level clustering and baseline rates. RESULTS Among 144 539 patient discharges at 21 randomized hospitals, there were 559 443 patient-days and 144 539 patients (100%) completed the trial. All-cause hospital mortality was 1.93 per 1000 patient discharges at hospitals with BedsidePEWS and 1.56 per 1000 patient discharges at hospitals with usual care (adjusted between-group rate difference, 0.01 [95% CI, -0.80 to 0.81 per 1000 patient discharges]; adjusted odds ratio, 1.01 [95% CI, 0.61 to 1.69]; P = .96). Significant clinical deterioration events occurred during 0.50 per 1000 patient-days at hospitals with BedsidePEWS vs 0.84 per 1000 patient-days at hospitals with usual care (adjusted between-group rate difference, -0.34 [95% CI, -0.73 to 0.05 per 1000 patient-days]; adjusted rate ratio, 0.77 [95% CI, 0.61 to 0.97]; P = .03). CONCLUSIONS AND RELEVANCE Implementation of the Bedside Paediatric Early Warning System compared with usual care did not significantly decrease all-cause mortality among hospitalized pediatric patients. These findings do not support the use of this system to reduce mortality. TRIAL REGISTRATION clinicaltrials.gov Identifier: NCT01260831.
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Affiliation(s)
- Christopher S. Parshuram
- Critical Care Program, Hospital for Sick Children, Toronto, Ontario, Canada
- Child Health Evaluative Sciences Program, SickKids Research Institute, Toronto, Ontario, Canada
- Centre for Safety Research, SickKids Research Institute, Toronto, Ontario, Canada
- Interdepartmental Division of Critical Care, University of Toronto, Toronto, Ontario, Canada
- Institute of Medical Science, University of Toronto, Toronto, Ontario, Canada
- Institute of Health Policy Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
- Centre for Quality Improvement and Patient Safety, University of Toronto, Toronto, Ontario, Canada
- Department of Paediatrics, University of Toronto, Toronto, Ontario, Canada
| | - Karen Dryden-Palmer
- Critical Care Program, Hospital for Sick Children, Toronto, Ontario, Canada
- Child Health Evaluative Sciences Program, SickKids Research Institute, Toronto, Ontario, Canada
- Centre for Safety Research, SickKids Research Institute, Toronto, Ontario, Canada
| | - Catherine Farrell
- Division of Pediatric Intensive Care, Centre Hospitalier Universitaire de Ste-Justine, Montreal, Quebec, Canada
| | | | - Martin Gray
- Critical Care Program, Hospital for Sick Children, Toronto, Ontario, Canada
- Interdepartmental Division of Critical Care, University of Toronto, Toronto, Ontario, Canada
- Institute of Medical Science, University of Toronto, Toronto, Ontario, Canada
- Department of Paediatrics, University of Toronto, Toronto, Ontario, Canada
- Department of Paediatrics, Hospital for Sick Children, Toronto, Ontario, Canada
- Neuroscience and Mental Health Research Program, SickKids Research Institute, Toronto, Ontario, Canada
| | - James S. Hutchison
- Critical Care Program, Hospital for Sick Children, Toronto, Ontario, Canada
- Interdepartmental Division of Critical Care, University of Toronto, Toronto, Ontario, Canada
- Institute of Medical Science, University of Toronto, Toronto, Ontario, Canada
- Department of Paediatrics, Hospital for Sick Children, Toronto, Ontario, Canada
- Neuroscience and Mental Health Research Program, SickKids Research Institute, Toronto, Ontario, Canada
| | - Mark Helfaer
- Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
| | | | - Ari R. Joffe
- Stollery Children’s Hospital, University of Alberta, Edmonton, Canada
| | - Jacques Lacroix
- Division of Pediatric Intensive Care, Centre Hospitalier Universitaire de Ste-Justine, Montreal, Quebec, Canada
| | - Michael Alice Moga
- Critical Care Program, Hospital for Sick Children, Toronto, Ontario, Canada
- Interdepartmental Division of Critical Care, University of Toronto, Toronto, Ontario, Canada
- Department of Paediatrics, University of Toronto, Toronto, Ontario, Canada
| | - Vinay Nadkarni
- Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Nelly Ninis
- St Mary’s Imperial Healthcare, London, England
| | - Patricia C. Parkin
- Child Health Evaluative Sciences Program, SickKids Research Institute, Toronto, Ontario, Canada
- Institute of Health Policy Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
- Department of Paediatrics, University of Toronto, Toronto, Ontario, Canada
- Department of Paediatrics, Hospital for Sick Children, Toronto, Ontario, Canada
| | - David Wensley
- British Columbia Children’s Hospital, Vancouver, Canada
| | - Andrew R. Willan
- Ontario Child Health Support Unit, SickKids Research Institute, Toronto, Canada
| | - George A. Tomlinson
- Institute of Health Policy Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
- Department of Medicine, University Health Network and Mt Sinai Hospital, Toronto, Ontario, Canada
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20
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Hutton E, Hannah ME, Willan AR, Ross S, Allen A, Armson BA, Gafni A, Joseph K, Mangoff K, Ohlsson A, Sanchez J, Asztalos EV, Barrett JFR. 224: Urinary incontinence 2 years after cesarean or vaginal birth for twin pregnancy: A multicenter randomized trial. Am J Obstet Gynecol 2018. [DOI: 10.1016/j.ajog.2017.10.152] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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Chan KKW, Xie F, Willan AR, Pullenayegum EM. Conducting EQ-5D Valuation Studies in Resource-Constrained Countries: The Potential Use of Shrinkage Estimators to Reduce Sample Size. Med Decis Making 2017; 38:26-33. [PMID: 28823185 DOI: 10.1177/0272989x17725748] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND Resource-constrained countries have difficulty conducting large EQ-5D valuation studies, which limits their ability to conduct cost-utility analyses using a value set specific to their own population. When estimates of similar but related parameters are available, shrinkage estimators reduce uncertainty and yield estimators with smaller mean square error (MSE). We hypothesized that health utilities based on shrinkage estimators can reduce MSE and mean absolute error (MAE) when compared to country-specific health utilities. METHODS We conducted a simulation study (1,000 iterations) based on the observed means and standard deviations (or standard errors) of the EQ-5D-3L valuation studies from 14 counties. In each iteration, the simulated data were fitted with the model based on the country-specific functional form of the scoring algorithm to create country-specific health utilities ("naïve" estimators). Shrinkage estimators were calculated based on the empirical Bayes estimation methods. The performance of shrinkage estimators was compared with those of the naïve estimators over a range of different sample sizes based on MSE, MAE, mean bias, standard errors and the width of confidence intervals. RESULTS The MSE of the shrinkage estimators was smaller than the MSE of the naïve estimators on average, as theoretically predicted. Importantly, the MAE of the shrinkage estimators was also smaller than the MAE of the naïve estimators on average. In addition, the reduction in MSE with the use of shrinkage estimators did not substantially increase bias. The degree of reduction in uncertainty by shrinkage estimators is most apparent in valuation studies with small sample size. CONCLUSION Health utilities derived from shrinkage estimation allow valuation studies with small sample size to "borrow strength" from other valuation studies to reduce uncertainty.
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Affiliation(s)
- Kelvin K W Chan
- Division of Medical Oncology and Hematology, Sunnybrook Odette Cancer Centre, Toronto, ON, Canada (KKC).,Division of Biostatistics, Dalla Lana School of Public Health, University of Toronto, ON, Canada (KKC, EMP).,Canadian Centre for Applied Research in Cancer Control (ARCC), Toronto, ON, Canada (KKC)
| | - Feng Xie
- Department of Clinical Epidemiology & Biostatistics, McMaster University, ON, Canada (FX)
| | - Andrew R Willan
- Child Health Evaluative Sciences, Hospital for Sick Children, Toronto, ON, Canada (ARW, EMP)
| | - Eleanor M Pullenayegum
- Division of Biostatistics, Dalla Lana School of Public Health, University of Toronto, ON, Canada (KKC, EMP).,Child Health Evaluative Sciences, Hospital for Sick Children, Toronto, ON, Canada (ARW, EMP)
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22
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Hall NJ, Eaton S, Abbo O, Arnaud AP, Beaudin M, Brindle M, Bütter A, Davies D, Jancelewicz T, Johnson K, Keijzer R, Lapidus-Krol E, Offringa M, Piché N, Rintala R, Skarsgard E, Svensson JF, Ungar WJ, Wester T, Willan AR, Zani A, St Peter SD, Pierro A. Appendectomy versus non-operative treatment for acute uncomplicated appendicitis in children: study protocol for a multicentre, open-label, non-inferiority, randomised controlled trial. BMJ Paediatr Open 2017; 1:bmjpo-2017-000028. [PMID: 29637088 PMCID: PMC5843002 DOI: 10.1136/bmjpo-2017-000028] [Citation(s) in RCA: 37] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/03/2017] [Revised: 04/26/2017] [Accepted: 04/27/2017] [Indexed: 12/19/2022] Open
Abstract
BACKGROUND Appendectomy is considered the gold standard treatment for acute appendicitis. Recently the need for surgery has been challenged in both adults and children. In children there is growing clinician, patient and parental interest in non-operative treatment of acute appendicitis with antibiotics as opposed to surgery. To date no multicentre randomised controlled trials that are appropriately powered to determine efficacy of non-operative treatment (antibiotics) for acute appendicitis in children compared with surgery (appendectomy) have been performed. METHODS Multicentre, international, randomised controlled trial with a non-inferiority design. Children (age 5-16 years) with a clinical and/or radiological diagnosis of acute uncomplicated appendicitis will be randomised (1:1 ratio) to receive either laparoscopic appendectomy or treatment with intravenous (minimum 12 hours) followed by oral antibiotics (total course 10 days). Allocation to groups will be stratified by gender, duration of symptoms (> or <48 hours) and centre. Children in both treatment groups will follow a standardised treatment pathway. Primary outcome is treatment failure defined as additional intervention related to appendicitis requiring general anaesthesia within 1 year of randomisation (including recurrent appendicitis) or negative appendectomy. Important secondary outcomes will be reported and a cost-effectiveness analysis will be performed. The primary outcome will be analysed on a non-inferiority basis using a 20% non-inferiority margin. Planned sample size is 978 children. DISCUSSION The APPY trial will be the first multicentre randomised trial comparing non-operative treatment with appendectomy for acute uncomplicated appendicitis in children. The results of this trial have the potential to revolutionise the treatment of this common gastrointestinal emergency. The randomised design will limit the effect of bias on outcomes seen in other studies. TRIAL REGISTRATION NUMBER clinicaltrials.gov: NCT02687464. Registered on Jan 13th 2016.
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Affiliation(s)
- Nigel J Hall
- University Surgery Unit, Faculty of Medicine, University of Southampton, Southampton, Hampshire, UK
| | - Simon Eaton
- Developmental Biology & Cancer Programme, UCL Great Ormond Street Institute of Child Health, London, UK
| | - Olivier Abbo
- Pediatric Surgery Department, Hôpital des Enfants, Centre Hospitalier Universitaire Toulouse, Toulouse, France
| | - Alexis P Arnaud
- Paediatric Surgery Department, Hôpital Sud, Centre Hospitalier Universitaire, Rennes, France
| | - Marianne Beaudin
- Division of PediatricSurgery, Centre Hospitalier Universitaire Sainte-Justine, Montreal, Canada
| | - Mary Brindle
- Departments of Surgery and Community Health Sciences, Alberta Children's Hospital, Calgary, Alberta, Canada
| | - Andreana Bütter
- Division of Pediatric Surgery, Children’s Hospital, London Health Sciences Centre, London, Ontario, Canada
| | - Dafydd Davies
- Department of General and Thoracic Surgery, IWK Health Centre, Halifax, Nova Scotia, Canada
| | - Tim Jancelewicz
- Division of Pediatric Surgery, Le Bonheur Children's Hospital, University of Tennessee Health Science Center, Memphis, Tennessee, USA
| | - Kathy Johnson
- Department of Surgery, Children's Mercy Hospitals and Clinics, Kansas City, Missouri, USA
| | - Richard Keijzer
- Department of Surgery, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Eveline Lapidus-Krol
- Division of Thoracic and General Surgery, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Martin Offringa
- Child Health Evaluative Sciences, SickKids Research Institute, Toronto, Ontario, Canada
| | - Nelson Piché
- Division of PediatricSurgery, Centre Hospitalier Universitaire Sainte-Justine, Montreal, Canada
| | - Risto Rintala
- Department of Pediatric Surgery, Children's Hospital, Helsinki University Central Hospital, University of Helsinki, Helsinki, Finland
| | - Erik Skarsgard
- Department of Surgery, BC Children's Hospital, Vancouver, British Columbia, Canada
| | - Jan F Svensson
- Department of Pediatric Surgery, Astrid Lindgren Children's Hospital, Karolinska University Hospital, Stockholm, Sweden
| | - Wendy J Ungar
- Child Health Evaluative Sciences, SickKids Research Institute, Toronto, Ontario, Canada
| | - Tomas Wester
- Department of Pediatric Surgery, Astrid Lindgren Children's Hospital, Karolinska University Hospital, Stockholm, Sweden
| | - Andrew R Willan
- Ontario Child Health Support Unit, SickKids Research Institute, Toronto, Ontario, Canada
| | - Augusto Zani
- Division of Thoracic and General Surgery, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Shawn D St Peter
- Department of Surgery, Children's Mercy Hospitals and Clinics, Kansas City, Missouri, USA
| | - Agostino Pierro
- Division of Thoracic and General Surgery, The Hospital for Sick Children, Toronto, Ontario, Canada
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Henderson JL, Cheung A, Cleverley K, Chaim G, Moretti ME, de Oliveira C, Hawke LD, Willan AR, O'Brien D, Heffernan O, Herzog T, Courey L, McDonald H, Grant E, Szatmari P. Integrated collaborative care teams to enhance service delivery to youth with mental health and substance use challenges: protocol for a pragmatic randomised controlled trial. BMJ Open 2017; 7:e014080. [PMID: 28167747 PMCID: PMC5293997 DOI: 10.1136/bmjopen-2016-014080] [Citation(s) in RCA: 57] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/30/2016] [Revised: 11/29/2016] [Accepted: 01/05/2017] [Indexed: 01/18/2023] Open
Abstract
INTRODUCTION Among youth, the prevalence of mental health and addiction (MHA) disorders is roughly 20%, yet youth are challenged to access evidence-based services in a timely fashion. To address MHA system gaps, this study tests the benefits of an Integrated Collaborative Care Team (ICCT) model for youth with MHA challenges. A rapid, stepped-care approach geared to need in a youth-friendly environment is expected to result in better youth MHA outcomes. Moreover, the ICCT approach is expected to decrease service wait-times, be more youth-friendly and family-friendly, and be more cost-effective, providing substantial public health benefits. METHODS AND ANALYSIS In partnership with four community agencies, four adolescent psychiatry hospital departments, youth and family members with lived experience of MHA service use, and other stakeholders, we have developed an innovative model of collaborative, community-based service provision involving rapid access to needs-based MHA services. A total of 500 youth presenting for hospital-based, outpatient psychiatric service will be randomised to ICCT services or hospital-based treatment as usual, following a pragmatic randomised controlled trial design. The primary outcome variable will be the youth's functioning, assessed at intake, 6 months and 12 months. Secondary outcomes will include clinical change, youth/family satisfaction and perception of care, empowerment, engagement and the incremental cost-effectiveness ratio (ICER). Intent-to-treat analyses will be used on repeated-measures data, along with cost-effectiveness and cost-utility analyses, to determine intervention effectiveness. ETHICS AND DISSEMINATION Research Ethics Board approval has been received from the Centre for Addiction and Mental Health, as well as institutional ethical approval from participating community sites. This study will be conducted according to Good Clinical Practice guidelines. Participants will provide informed consent prior to study participation and data confidentiality will be ensured. A data safety monitoring panel will monitor the study. Results will be disseminated through community and peer-reviewed academic channels. TRIAL REGISTRATION NUMBER Clinicaltrials.gov NCT02836080.
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Affiliation(s)
| | - Amy Cheung
- Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Kristin Cleverley
- Bloomberg Faculty of Nursing, University of Toronto, Toronto, Ontario, Canada
| | - Gloria Chaim
- Centre for Addiction and Mental Health (CAMH), Toronto, Ontario, Canada
| | - Myla E Moretti
- Clinical Trials Unit, The Hospital for Sick Children, Toronto, Ontario, Canada
| | | | - Lisa D Hawke
- Centre for Addiction and Mental Health (CAMH), Toronto, Ontario, Canada
| | - Andrew R Willan
- SickKids Research Institute, Hospital for Sick Children, Toronto, Ontario, Canada
| | - David O'Brien
- East Metro Youth Services, Scarborough, Ontario, Canada
| | - Olivia Heffernan
- Centre for Addiction and Mental Health (CAMH), Toronto, Ontario, Canada
| | - Tyson Herzog
- Centre for Addiction and Mental Health (CAMH), Toronto, Ontario, Canada
| | - Lynn Courey
- Sashbear Foundation, Toronto, Ontario, Canada
| | | | - Enid Grant
- Youth and Families, Toronto, Ontario, Canada
| | - Peter Szatmari
- Centre for Addiction and Mental Health (CAMH), Toronto, Ontario, Canada
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Mei-Dan E, Asztalos EV, Willan AR, Barrett JFR. The effect of induction method in twin pregnancies: a secondary analysis for the twin birth study. BMC Pregnancy Childbirth 2017; 17:9. [PMID: 28061767 PMCID: PMC5217445 DOI: 10.1186/s12884-016-1201-8] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2015] [Accepted: 12/16/2016] [Indexed: 11/17/2022] Open
Abstract
Background This secondary analysis for the Twin Birth Study, an international, multicenter trial, aimed to compare the cesarean section rates and safety between methods of induction of labor in twin pregnancies. Methods Women with twin pregnancies where the first twin was in a cephalic presentation and who presented for labor induction, were non-randomly assigned to receive prostaglandin or amniotomy and/or oxytocin. Main outcome measures were the rates of unplanned cesarean section and neonatal and maternal mortality or serious morbidity. Results 153 (41.5%) were induced by prostaglandin (prostaglandin group) and 215 (58.5%) were induced by amniotomy and/or oxytocin alone (no prostaglandin group). Induction using prostaglandin was more common in countries with a low perinatal mortality rate <10/1000 (45.7 versus 32.5%, p = 0.02). Cesarean section rates were similar in the two groups: 62/153 (40.5%) in the prostaglandin group and 87/215 (40.5%) in the no prostaglandin group (odds ratio 1, 95% CI 0.65-1.5). Nulliparity, late maternal age, non-cephalic presentation of twin B and high country’s perinatal mortality rate were found to be independently associated with the induction to end with an unplanned cesarean section. There were no significant differences between groups with respect to maternal or neonatal adverse outcomes. Conclusions The need for cervical ripening by prostaglandin had no effect on the incidence of cesarean delivery or an abnormal outcome. There is a significant risk of unplanned cesarean section independent of chosen induction method. Trial registration This trial was registered at the International Standard Randomized Controlled Trial Register (identifier ISRCTN74420086; December 9, 2003) and retrospectively registered at the www.clinicaltrials.gov (identifier NCT 00187369; September 12, 2005). Electronic supplementary material The online version of this article (doi:10.1186/s12884-016-1201-8) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Elad Mei-Dan
- Women and Babies Program, Sunnybrook Health Sciences Center, Sunnybrook Research Institute, 2075 Bayview Ave, Toronto, ON, M4N 3M5, Canada.
| | - Elizabeth V Asztalos
- Women and Babies Program, Sunnybrook Health Sciences Center, Sunnybrook Research Institute, 2075 Bayview Ave, Toronto, ON, M4N 3M5, Canada
| | - Andrew R Willan
- Child Health Evaluative Sciences, SickKids Research Institute, University of Toronto, The Hospital for Sick Children, 555 University Avenue, Toronto, M5G 1X8, ON, Canada
| | - Jon F R Barrett
- Women and Babies Program, Sunnybrook Health Sciences Center, Sunnybrook Research Institute, 2075 Bayview Ave, Toronto, ON, M4N 3M5, Canada
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Shea A, Murphy KE, Asztalos E, Willan AR, Sanchez J. 805: Postpartum depression assessment in the Multiple Courses of Antenatal Corticosteroids for Preterm Birth Study (MACS). Am J Obstet Gynecol 2017. [DOI: 10.1016/j.ajog.2016.11.538] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Chan KKW, Xie F, Willan AR, Pullenayegum EM. Underestimation of Variance of Predicted Health Utilities Derived from Multiattribute Utility Instruments. Med Decis Making 2016; 37:262-272. [PMID: 27216582 DOI: 10.1177/0272989x16650181] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Parameter uncertainty in value sets of multiattribute utility-based instruments (MAUIs) has received little attention previously. This false precision leads to underestimation of the uncertainty of the results of cost-effectiveness analyses. The aim of this study is to examine the use of multiple imputation as a method to account for this uncertainty of MAUI scoring algorithms. METHOD We fitted a Bayesian model with random effects for respondents and health states to the data from the original US EQ-5D-3L valuation study, thereby estimating the uncertainty in the EQ-5D-3L scoring algorithm. We applied these results to EQ-5D-3L data from the Commonwealth Fund (CWF) Survey for Sick Adults ( n = 3958), comparing the standard error of the estimated mean utility in the CWF population using the predictive distribution from the Bayesian mixed-effect model (i.e., incorporating parameter uncertainty in the value set) with the standard error of the estimated mean utilities based on multiple imputation and the standard error using the conventional approach of using MAUI (i.e., ignoring uncertainty in the value set). RESULT The mean utility in the CWF population based on the predictive distribution of the Bayesian model was 0.827 with a standard error (SE) of 0.011. When utilities were derived using the conventional approach, the estimated mean utility was 0.827 with an SE of 0.003, which is only 25% of the SE based on the full predictive distribution of the mixed-effect model. Using multiple imputation with 20 imputed sets, the mean utility was 0.828 with an SE of 0.011, which is similar to the SE based on the full predictive distribution. CONCLUSION Ignoring uncertainty of the predicted health utilities derived from MAUIs could lead to substantial underestimation of the variance of mean utilities. Multiple imputation corrects for this underestimation so that the results of cost-effectiveness analyses using MAUIs can report the correct degree of uncertainty.
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Affiliation(s)
- Kelvin K W Chan
- Sunnybrook Health Sciences Centre, Division of Medical Oncology, Department of Medicine, Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada (KKWC).,Division of Biostatistics, Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada (KKWC, ARW, EP).,Canadian Centre for Applied Research in Cancer Control, Canada (KKWC)
| | - Feng Xie
- Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Ontario, Canada (FX).,Father Sean O'Sullivan Research Centre, St. Joseph's Healthcare Hamilton, Hamilton, Ontario, Canada (FX).,Program for Health Economics and Outcome Measures, Hamilton, Ontario, Canada (FX)
| | - Andrew R Willan
- Division of Biostatistics, Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada (KKWC, ARW, EP).,Ontario Child Health Support Unit, SickKids Research Institute, Toronto, Ontario, Canada (ARW)
| | - Eleanor M Pullenayegum
- Division of Biostatistics, Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada (KKWC, ARW, EP).,Program in Child Health Evaluative Sciences, SickKids Research Institute, Toronto, Ontario, Canada (EP)
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Willan AR. Accounting for treatment by center interaction in sample size determinations and the use of surrogate outcomes in the pessary for the prevention of preterm birth trial: a simulation study. Trials 2016; 17:310. [PMID: 27378231 PMCID: PMC4932689 DOI: 10.1186/s13063-016-1433-y] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2015] [Accepted: 06/08/2016] [Indexed: 11/10/2022] Open
Abstract
Background The Pessary for the Prevention of Preterm Birth Study (PS3) is an international, multicenter, randomized clinical trial designed to examine the effectiveness of the Arabin pessary in preventing preterm birth in pregnant women with a short cervix. During the design of the study two methodological issues regarding power and sample size were raised. Since treatment in the Standard Arm will vary between centers, it is anticipated that so too will the probability of preterm birth in that arm. This will likely result in a treatment by center interaction, and the issue of how this will affect the sample size requirements was raised. The sample size requirements to examine the effect of the pessary on the baby’s clinical outcome was prohibitively high, so the second issue is how best to examine the effect on clinical outcome. The approaches taken to address these issues are presented. Results Simulation and sensitivity analysis were used to address the sample size issue. The probability of preterm birth in the Standard Arm was assumed to vary between centers following a Beta distribution with a mean of 0.3 and a coefficient of variation of 0.3. To address the second issue a Bayesian decision model is proposed that combines the information regarding the between-treatment difference in the probability of preterm birth from PS3 with the data from the Multiple Courses of Antenatal Corticosteroids for Preterm Birth Study that relate preterm birth and perinatal mortality/morbidity. The approach provides a between-treatment comparison with respect to the probability of a bad clinical outcome. The performance of the approach was assessed using simulation and sensitivity analysis. Accounting for a possible treatment by center interaction increased the sample size from 540 to 700 patients per arm for the base case. The sample size requirements increase with the coefficient of variation and decrease with the number of centers. Under the same assumptions used for determining the sample size requirements, the simulated mean probability that pessary reduces the risk of perinatal mortality/morbidity is 0.98. The simulated mean decreased with coefficient of variation and increased with the number of clinical sites. Conclusion Employing simulation and sensitivity analysis is a useful approach for determining sample size requirements while accounting for the additional uncertainty due to a treatment by center interaction. Using a surrogate outcome in conjunction with a Bayesian decision model is an efficient way to compare important clinical outcomes in a randomized clinical trial in situations where the direct approach requires a prohibitively high sample size.
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Affiliation(s)
- Andrew R Willan
- Ontario Child Health Support Unit, Sickkids Research Institute, 555 University Avenue, Toronto, ON, M5G 1X8, Canada.
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Abstract
Background The results of the HOPE study, a randomized clinical trial, provide strong evidence that 1) ramipril prevents the composite outcome of cardiovascular death, myocardial infarction or stroke in patients who are at high risk of a cardiovascular event and 2) ramipril is cost-effective at a threshold willingness-to-pay of $10 000 to prevent an event of the composite outcome. In this report the concept of the expected value of information is used to determine if the information provided by the HOPE study is sufficient for decision making in the US and Canada. Methods and results Using the cost-effectiveness data from a clinical trial, or from a meta-analysis of several trials, one can determine, based on the number of future patients that would benefit from the health technology under investigation, the expected value of sample information (EVSI) of a future trial as a function of proposed sample size. If the EVSI exceeds the cost for any particular sample size then the current information is insufficient for decision making and a future trial is indicated. If, on the other hand, there is no sample size for which the EVSI exceeds the cost, then there is sufficient information for decision making and no future trial is required. Using the data from the HOPE study these concepts are applied for various assumptions regarding the fixed and variable cost of a future trial and the number of patients who would benefit from ramipril. Conclusions Expected value of information methods provide a decision-analytic alternative to the standard likelihood methods for assessing the evidence provided by cost-effectiveness data from randomized clinical trials. Clinical Trials 2007; 4: 279—285. http://ctj.sagepub.com
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Affiliation(s)
- Andrew R Willan
- Program in Child Health Evaluation Sciences, SickKids Research Institute and Department of Public Health Sciences, University of Toronto, Toronto, Canada.
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Hutton EK, Hannah ME, Ross S, Joseph KS, Ohlsson A, Asztalos E, Willan AR, Allen AC, Armson BA, Gafni A, Mangoff K, Sanchez JJ, Barrett JF. Re: Maternal outcomes at 3 months after planned caesarean section versus planned vaginal birth for twin pregnancies in the Twin Birth Study: a randomised controlled trial: Counselling is difficult when outcomes are associated with mode of delivery and not the plan of mode of delivery. BJOG 2016; 123:644. [PMID: 26914900 DOI: 10.1111/1471-0528.13769] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/16/2015] [Indexed: 11/29/2022]
Affiliation(s)
- Eileen K Hutton
- Faculty of Health Sciences, McMaster University, Hamilton, ON, Canada
| | - Mary E Hannah
- Department of Obstetrics and Gynaecology, University of Toronto, Toronto, ON, Canada
| | - Susan Ross
- Obstetrics and Gynecology, University of Alberta, Edmonton, AB, Canada
| | - K S Joseph
- Obstetrics and Gynaecology and School of Population and Public Health, University of British Columbia, Vancouver, BC, Canada
| | - Arne Ohlsson
- Pediatrics, Mount Sinai Hospital, University of Toronto, Toronto, ON, Canada
| | - Elizabeth Asztalos
- Department of Newborn and Developmental Paediatrics, Sunnybrook Health Sciences Center, University of Toronto, Toronto, ON, Canada
| | - Andrew R Willan
- Ontario Child Health Support Unit, Sickkids Research Institute and Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada
| | - Alexander C Allen
- Pediatrics, IWK Health Center, Dalhousie University, Halifax, NS, Canada
| | - B Anthony Armson
- Obstetrics and Gynecology, IWK Health Center, Dalhousie University, Halifax, NS, Canada
| | - Amiram Gafni
- Faculty of Health Sciences, McMaster University, Hamilton, ON, Canada
| | - Kathryn Mangoff
- Center for Mother, Infant and Child Research, Sunnybrook Research Institute, University of Toronto, Toronto, ON, Canada
| | - Johanna J Sanchez
- Center for Mother, Infant and Child Research, Sunnybrook Research Institute, University of Toronto, Toronto, ON, Canada
| | - Jon F Barrett
- Department of Obstetrics and Gynaecology, University of Toronto, Toronto, ON, Canada
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Schuh S, Sweeney J, Freedman SB, Coates AL, Johnson DW, Thompson G, Gravel J, Ducharme FM, Zemek R, Plint AC, Beer D, Klassen T, Curtis S, Black K, Nicksy D, Willan AR. Magnesium nebulization utilization in management of pediatric asthma (MagNUM PA) trial: study protocol for a randomized controlled trial. Trials 2016; 17:261. [PMID: 27220675 PMCID: PMC4879727 DOI: 10.1186/s13063-015-1151-x] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2015] [Accepted: 12/30/2015] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND Up to 30 % of children with acute asthma are refractory to initial therapy, and 84 % of this subpopulation needs hospitalization. Finding safe, noninvasive, and effective strategies to treat this high-risk group would substantially decrease hospitalizations, healthcare costs, and the psycho-social burden of the disease. Whereas intravenous magnesium (Mg) is effective in severe refractory asthma, its use is sporadic due to safety concerns, with the main treatment goal being to prevent intensive care unit admission. In contrast, nebulized Mg is noninvasive, allows higher pulmonary drug concentrations, and has a much higher safety potential due to the lower rate of systemic delivery. Previous studies of inhaled Mg show disparate results due to the use of unknown/inefficient delivery methods and other methodological flaws. METHODS/DESIGN The study is a randomized double-blind controlled trial in seven Canadian pediatric Emergency Departments (two-center pilot 2011 to 2014, Canada-wide November 2014 to December 2017). The trial will include 816 otherwise healthy children who are 2 to 17 years old, having had at least one previous wheezing episode, have received systemic corticosteroids, and have a Pediatric Respiratory Assessment Measure (PRAM) ≥ 5 points after three salbutamol and ipratropium treatments for a current acute asthma exacerbation. Eligible consenting children will receive three experimental treatments of nebulized salbutamol with either 600 mg of Mg sulfate or placebo 20 min apart, using an Aeroneb Go nebulizer, which has been shown to maximize pulmonary delivery while maintaining safety. The primary outcome is hospitalization within 24 h of the start of the experimental therapy for persistent respiratory distress or supplemental oxygen. Secondary outcomes include all-cause hospitalization within 24 h, PRAM, vital signs, number of bronchodilator treatments by 240 min, and the association between the difference in the primary outcome between the groups, age, gender, baseline PRAM, atopy, and "viral induced wheeze" phenotype (Fig. 1). DISCUSSION If effective, inhaled Mg may represent an effective strategy to minimize morbidity in pediatric refractory acute asthma. Unlike previous works, this trial targets nonresponders to optimized initial therapy who are the most likely to benefit from inhaled Mg. Future dissemination of results will include knowledge translation, incorporation into a Cochrane Review, presentation at scientific meetings, and a peer-reviewed publication. TRIAL REGISTRATION NCTO1429415 , registered 2 September 2011.
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Affiliation(s)
- Suzanne Schuh
- />Division of Paediatric Emergency Medicine, The Hospital for Sick Children, Child Health Evaluative Sciences, SickKids Research Institute, University of Toronto, 555 University Avenue, Toronto, ON M5G 1X8 Canada
| | - Judy Sweeney
- />SickKids Research Institute, The Hospital for Sick Children, 555 University Ave, Toronto, ON M5G 1X8 Canada
| | - Stephen B. Freedman
- />Sections of Pediatric Emergency Medicine and Gastroenterology, Alberta Children’s Hospital, Alberta Children’s Hospital Research Institute, University of Calgary, 2888 Shaganappi Trail NW, Calgary, AB T3B 6AB Canada
| | - Allan L. Coates
- />SickKids Research Institute, The Hospital for Sick Children, University of Toronto, 555 University Avenue, Toronto, ON M5G 1X8 Canada
| | - David W. Johnson
- />Departments of Paediatrics, Pharmacology and Physiology, Alberta Children’s Hospital Research Institute, Faculty of Medicine, University of Calgary, C4,643, 2888 Shaganappi Trail NW, Calgary, AB T3B 6AB Canada
| | - Graham Thompson
- />Division of Pediatric Emergency Medicine, Alberta Children’s Hospital, University of Calgary, 2888 Shaganappi Trail NW, Calgary, AB T3B 6AB Canada
| | - Jocelyn Gravel
- />Division of Paediatric Emergency Medicine, Department of Pediatrics, Centre Hospitalier Universitaire Ste-Justine, Université de Montréal, 3175 Cote Sainte-Catherine, Montreal, QC H3T 1C5 Canada
| | - Francine M. Ducharme
- />Department of Pediatrics, Centre Hospitalier Universitaire Ste-Justine, Université de Montréal, 175 Cote Sainte-Catherine, Montreal, QC H3T 1C5 Canada
| | - Roger Zemek
- />Division of Pediatric Emergency Medicine, Children’s Hospital of Eastern Ontario (CHEO), 401 Smyth Road, Ottawa, ON K1H 8L1 Canada
| | - Amy C. Plint
- />Division of Emergency Medicine, Children’s Hospital of Eastern Ontario (CHEO), 401 Smyth Road, Ottawa, ON K1H 8L1 Canada
| | - Darcy Beer
- />Divsion of Pediatric Emergency Medicine, The Children’s Hospital of Winnipeg, University of Manitoba, 820 Sherbrook Street, Winnipeg, MB R3J 1R9 Canada
| | - Terry Klassen
- />Children’s Hospital Research Institute of Manitoba (formerly Manitoba Institute of Child Health), Academic Faculty of Medicine, 715 McDermot Ave, Winnipeg, MB R3E 3P4 Canada
- />Department of Pediatrics and Child Health, University of Manitoba, 715 McDermot Ave, Winnipeg, MB R3E 3P4 Canada
- />Child Health Program, Winnipeg Health Region MICH, 715 McDermot Ave, Winnipeg, MB R3E 3P4 Canada
| | - Sarah Curtis
- />Division of Paediatric Emergency Medicine, Stollery Children’s Hospital, University of Alberta, 8440 112 Street Northwest, Edmonton, AB T6G 2B7 Canada
| | - Karen Black
- />Division of Pediatric Emergency Medicine, University of British Columbia, BC Children’s Hospital, 4480 Oak St, Vancouver, BC V6H 3N1 Canada
| | - Darcy Nicksy
- />SickKids Research Institute, The Hospital for Sick Children, 555 University Ave, Toronto, ON M5G 1X8 Canada
| | - Andrew R. Willan
- />Child Health Evaluative Sciences, SickKids Research Institute, Dalla Lana School of Public Health, University of Toronto, 555 University Avenue, Toronto, ON M5G 1X8 Canada
| | - on behalf of Pediatric Emergency Research Canada Group
- />Division of Paediatric Emergency Medicine, The Hospital for Sick Children, Child Health Evaluative Sciences, SickKids Research Institute, University of Toronto, 555 University Avenue, Toronto, ON M5G 1X8 Canada
- />Sections of Pediatric Emergency Medicine and Gastroenterology, Alberta Children’s Hospital, Alberta Children’s Hospital Research Institute, University of Calgary, 2888 Shaganappi Trail NW, Calgary, AB T3B 6AB Canada
- />Departments of Paediatrics, Pharmacology and Physiology, Alberta Children’s Hospital Research Institute, Faculty of Medicine, University of Calgary, C4,643, 2888 Shaganappi Trail NW, Calgary, AB T3B 6AB Canada
- />Division of Pediatric Emergency Medicine, Alberta Children’s Hospital, University of Calgary, 2888 Shaganappi Trail NW, Calgary, AB T3B 6AB Canada
- />Division of Paediatric Emergency Medicine, Department of Pediatrics, Centre Hospitalier Universitaire Ste-Justine, Université de Montréal, 3175 Cote Sainte-Catherine, Montreal, QC H3T 1C5 Canada
- />Department of Pediatrics, Centre Hospitalier Universitaire Ste-Justine, Université de Montréal, 175 Cote Sainte-Catherine, Montreal, QC H3T 1C5 Canada
- />Division of Pediatric Emergency Medicine, Children’s Hospital of Eastern Ontario (CHEO), 401 Smyth Road, Ottawa, ON K1H 8L1 Canada
- />Division of Emergency Medicine, Children’s Hospital of Eastern Ontario (CHEO), 401 Smyth Road, Ottawa, ON K1H 8L1 Canada
- />Divsion of Pediatric Emergency Medicine, The Children’s Hospital of Winnipeg, University of Manitoba, 820 Sherbrook Street, Winnipeg, MB R3J 1R9 Canada
- />Children’s Hospital Research Institute of Manitoba (formerly Manitoba Institute of Child Health), Academic Faculty of Medicine, 715 McDermot Ave, Winnipeg, MB R3E 3P4 Canada
- />Department of Pediatrics and Child Health, University of Manitoba, 715 McDermot Ave, Winnipeg, MB R3E 3P4 Canada
- />Child Health Program, Winnipeg Health Region MICH, 715 McDermot Ave, Winnipeg, MB R3E 3P4 Canada
- />Division of Paediatric Emergency Medicine, Stollery Children’s Hospital, University of Alberta, 8440 112 Street Northwest, Edmonton, AB T6G 2B7 Canada
- />Division of Pediatric Emergency Medicine, University of British Columbia, BC Children’s Hospital, 4480 Oak St, Vancouver, BC V6H 3N1 Canada
- />SickKids Research Institute, The Hospital for Sick Children, University of Toronto, 555 University Avenue, Toronto, ON M5G 1X8 Canada
- />Child Health Evaluative Sciences, SickKids Research Institute, Dalla Lana School of Public Health, University of Toronto, 555 University Avenue, Toronto, ON M5G 1X8 Canada
- />SickKids Research Institute, The Hospital for Sick Children, 555 University Ave, Toronto, ON M5G 1X8 Canada
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Freedman SB, Willan AR, Boutis K, Schuh S. Effect of Dilute Apple Juice and Preferred Fluids vs Electrolyte Maintenance Solution on Treatment Failure Among Children With Mild Gastroenteritis: A Randomized Clinical Trial. JAMA 2016; 315:1966-74. [PMID: 27131100 DOI: 10.1001/jama.2016.5352] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
IMPORTANCE Gastroenteritis is a common pediatric illness. Electrolyte maintenance solution is recommended to treat and prevent dehydration. Its advantage in minimally dehydrated children is unproven. OBJECTIVE To determine if oral hydration with dilute apple juice/preferred fluids is noninferior to electrolyte maintenance solution in children with mild gastroenteritis. DESIGN, SETTING, AND PARTICIPANTS Randomized, single-blind noninferiority trial conducted between the months of October and April during the years 2010 to 2015 in a tertiary care pediatric emergency department in Toronto, Ontario, Canada. Study participants were children aged 6 to 60 months with gastroenteritis and minimal dehydration. INTERVENTIONS Participants were randomly assigned to receive color-matched half-strength apple juice/preferred fluids (n=323) or apple-flavored electrolyte maintenance solution (n=324). Oral rehydration therapy followed institutional protocols. After discharge, the half-strength apple juice/preferred fluids group was administered fluids as desired; the electrolyte maintenance solution group replaced losses with electrolyte maintenance solution. MAIN OUTCOMES AND MEASURES The primary outcome was a composite of treatment failure defined by any of the following occurring within 7 days of enrollment: intravenous rehydration, hospitalization, subsequent unscheduled physician encounter, protracted symptoms, crossover, and 3% or more weight loss or significant dehydration at in-person follow-up. Secondary outcomes included intravenous rehydration, hospitalization, and frequency of diarrhea and vomiting. The noninferiority margin was defined as a difference between groups of 7.5% for the primary outcome and was assessed with a 1-sided α=.025. If noninferiority was established, a 1-sided test for superiority was conducted. RESULTS Among 647 randomized children (mean age, 28.3 months; 331 boys [51.1%]; 441 (68.2%) without evidence of dehydration), 644 (99.5%) completed follow-up. Children who were administered dilute apple juice experienced treatment failure less often than those given electrolyte maintenance solution (16.7% vs 25.0%; difference, -8.3%; 97.5% CI, -∞ to -2.0%; P < .001 for inferiority and P = .006 for superiority). Fewer children administered apple juice/preferred fluids received intravenous rehydration (2.5% vs 9.0%; difference, -6.5%; 99% CI, -11.6% to -1.8%). Hospitalization rates and diarrhea and vomiting frequency were not significantly different between groups. CONCLUSIONS AND RELEVANCE Among children with mild gastroenteritis and minimal dehydration, initial oral hydration with dilute apple juice followed by their preferred fluids, compared with electrolyte maintenance solution, resulted in fewer treatment failures. In many high-income countries, the use of dilute apple juice and preferred fluids as desired may be an appropriate alternative to electrolyte maintenance fluids in children with mild gastroenteritis and minimal dehydration. TRIAL REGISTRATION clinicaltrials.gov Identifier: NCT01185054.
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Affiliation(s)
- Stephen B Freedman
- Sections of Pediatric Emergency Medicine and Gastroenterology, Alberta Children's Hospital, and Alberta Children's Hospital Research Institute, University of Calgary, Calgary, Canada
| | - Andrew R Willan
- Ontario Child Health Support Unit, Hospital for Sick Children Research Institute, Dalla Lana School of Public Health, University of Toronto, Faculty of Medicine, Toronto, Ontario, Canada
| | - Kathy Boutis
- Division of Pediatric Emergency Medicine, The Hospital for Sick Children and Child Health Evaluative Sciences, Toronto, Ontario, Canada4Hospital for Sick Children Research Institute, Department of Pediatrics, University of Toronto, Faculty of Medicine, To
| | - Suzanne Schuh
- Division of Pediatric Emergency Medicine, The Hospital for Sick Children and Child Health Evaluative Sciences, Toronto, Ontario, Canada4Hospital for Sick Children Research Institute, Department of Pediatrics, University of Toronto, Faculty of Medicine, To
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Escott BG, Richmond SA, Willan AR, Ravi B, Howard AW. The impact of pedestrian countdown signals on single and two vehicle motor vehicle collisions: a quasi-experimental study. Int J Inj Contr Saf Promot 2016; 24:429-434. [PMID: 27142464 DOI: 10.1080/17457300.2016.1177551] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
The objective of this study was to examine the impact of pedestrian countdown signals (PCS) on the rate of motor vehicle collisions (MVCs) in Toronto, Canada. A quasi-experimental design was used to compare rates of single and two vehicle MVCs before and after installation of PCS in Toronto, Canada between January 2005 and December 2009. Collision incidence rates were compared using Poisson regression analyses with adjustment for relevant cofounders and reported as incidence rate ratios (IRR) with 95% confidence intervals (CI). Secondary analyses were performed on subsets of collisions by collision type and injury severity. A total of 94,175 MVCs occurred at or near 1965 intersections at which PCS were installed over the five-year study period. Overall, the MVC incidence rate increased 7.5% (IRR = 1.075; 95% CI: 1.042-1.109; p < 0.0001) after installation of PCS. The installation of PCS led to an increase in MVCs. PCS may have an unintended consequence of increasing the rate of MVCs.
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Affiliation(s)
- Benjamin G Escott
- a Division of Orthopaedic Surgery , University of Toronto , Toronto , Canada
| | - Sarah A Richmond
- b Child Health Evaluative Sciences , The Hospital for Sick Children , Toronto , Canada
| | - Andrew R Willan
- b Child Health Evaluative Sciences , The Hospital for Sick Children , Toronto , Canada.,c Dalla Lana School of Public Health , University of Toronto , Toronto , Canada
| | - Bheeshma Ravi
- a Division of Orthopaedic Surgery , University of Toronto , Toronto , Canada
| | - Andrew W Howard
- b Child Health Evaluative Sciences , The Hospital for Sick Children , Toronto , Canada.,d Division of Orthopaedic Surgery , The Hospital for Sick Children , Toronto , Canada.,e Institute of Health, Policy, Management and Evaluation , University of Toronto , Toronto , Canada.,f Department of Surgery , University of Toronto , Toronto , Canada
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Asztalos EV, Hannah ME, Hutton EK, Willan AR, Allen AC, Armson BA, Gafni A, Joseph K, Ohlsson A, Ross S, Sanchez JJ, Mangoff K, Barrett JF. Twin Birth Study: 2-year neurodevelopmental follow-up of the randomized trial of planned cesarean or planned vaginal delivery for twin pregnancy. Am J Obstet Gynecol 2016; 214:371.e1-371.e19. [PMID: 26830380 DOI: 10.1016/j.ajog.2015.12.051] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2015] [Revised: 12/13/2015] [Accepted: 12/29/2015] [Indexed: 10/22/2022]
Abstract
BACKGROUND The Twin Birth Study randomized women with uncomplicated pregnancies, between 32(0/7)-38(6/7) weeks' gestation where the first twin was in cephalic presentation, to a policy of either a planned cesarean or planned vaginal delivery. The primary analysis showed that planned cesarean delivery did not increase or decrease the risk of fetal/neonatal death or serious neonatal morbidity as compared with planned vaginal delivery. OBJECTIVE This study presents the secondary outcome of death or neurodevelopmental delay at 2 years of age. STUDY DESIGN A total of 4603 children from the initial cohort of 5565 fetuses/infants (83%) contributed to the outcome of death or neurodevelopmental delay. Surviving children were screened using the Ages and Stages Questionnaire with abnormal scores validated by a clinical neurodevelopmental assessment. The effect of planned cesarean vs planned vaginal delivery on death or neurodevelopmental delay was quantified using a logistic model to control for stratification variables and using generalized estimating equations to account for the nonindependence of twin births. RESULTS Baseline maternal, pregnancy, and infant characteristics were similar. Mean age at assessment was 26 months. There was no significant difference in the outcome of death or neurodevelopmental delay: 5.99% in the planned cesarean vs 5.83% in the planned vaginal delivery group (odds ratio, 1.04; 95% confidence interval, 0.77-1.41; P = .79). CONCLUSION A policy of planned cesarean delivery provides no benefit to children at 2 years of age compared with a policy of planned vaginal delivery in uncomplicated twin pregnancies between 32(0/7)-38(6/7)weeks' gestation where the first twin is in cephalic presentation.
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Affiliation(s)
- Simon Eckermann
- Australian Health Services Research Institute, University of Wollongong, Wollongong, New South Wales, Australia (SDE)
- Child Health Evaluative Sciences, SickKids Research Institute, Toronto, Ontario, Canada (ARW)
| | - Andrew R. Willan
- Australian Health Services Research Institute, University of Wollongong, Wollongong, New South Wales, Australia (SDE)
- Child Health Evaluative Sciences, SickKids Research Institute, Toronto, Ontario, Canada (ARW)
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Mei-Dan E, Asztalos EV, Melamed N, Willan AR, Barrett JF. 284: Cesarean versus vaginal delivery for women in spontaneous labor of twin pregnancy: A secondary analysis of the Twin Birth Study. Am J Obstet Gynecol 2016. [DOI: 10.1016/j.ajog.2015.10.323] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Hutton EK, Hannah ME, Ross S, Joseph KS, Ohlsson A, Asztalos EV, Willan AR, Allen AC, Armson BA, Gafni A, Mangoff K, Sanchez JJ, Barrett JF. Maternal outcomes at 3 months after planned caesarean section versus planned vaginal birth for twin pregnancies in the Twin Birth Study: a randomised controlled trial. BJOG 2015; 122:1653-62. [PMID: 26328526 PMCID: PMC5014197 DOI: 10.1111/1471-0528.13597] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/01/2015] [Indexed: 12/16/2022]
Abstract
OBJECTIVE To compare outcomes at 3 months post partum for women randomised to give birth by planned caesarean section (CS) or by planned vaginal birth (VB) in the Twin Birth Study (TBS). DESIGN We invited women in the TBS to complete a 3-month follow-up questionnaire. SETTING Two thousand and eight hundred and four women from 25 countries. POPULATION Two thousand and five hundred and seventy women (92% response rate). METHODS Women randomised between 13 December 2003 and 4 April 2011 in the TBS completed a questionnaire and outcomes were compared using an intention-to-treat approach. MAIN OUTCOME AND MEASURES Breastfeeding, quality of life, depression, fatigue and urinary incontinence. RESULTS We found no clinically important differences between groups in any outcome. In the planned CS versus planned VB groups, breastfeeding at any time after birth was reported by 84.4% versus 86.4% (P = 0.13); the mean physical and mental Short Form (36) Health Survey (SF-36) quality of life scores were 51.8 versus 51.6 (P = 0.65) and 46.7 versus 46.0 (P = 0.09), respectively; the mean Multidimensional Assessment of Fatigue score was 20.3 versus 20.8 (P = 0.14); the frequency of probable depression on the Edinburgh Postnatal Depression Scale was 14.0% versus 14.8% (P = 0.57); the rate of problematic urinary incontinence was 5.5% versus 6.4% (P = 0.31); and the mean Incontinence Impact Questionnaire-7 score was 20.5 versus 20.4 (P = 0.99). Partner relationships, including painful intercourse, were similar between the groups. CONCLUSION For women with twin pregnancies randomised to planned CS compared with planned VB, outcomes at 3 months post partum did not differ. The mode of birth was not associated with problematic urinary incontinence or urinary incontinence that affected the quality of life. Contrary to previous studies, breastfeeding at 3 months was not increased with planned VB. TWEETABLE ABSTRACT Planned mode of birth for twins doesn't affect maternal depression, wellbeing, incontinence or breastfeeding.
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Affiliation(s)
- EK Hutton
- Faculty of Health SciencesMcMaster UniversityHamiltonONCanada
| | - ME Hannah
- Department of Obstetrics and GynaecologyUniversity of TorontoTorontoONCanada
| | - S Ross
- Obstetrics and GynecologyUniversity of AlbertaEdmontonABCanada
| | - KS Joseph
- Obstetrics and Gynaecology and School of Population and Public HealthUniversity of British ColumbiaVancouverBCCanada
| | - A Ohlsson
- PediatricsMount Sinai HospitalUniversity of TorontoTorontoONCanada
| | - EV Asztalos
- Department of Newborn and Developmental PaediatricsSunnybrook Health Sciences CenterUniversity of TorontoTorontoONCanada
| | - AR Willan
- Ontario Child Health Support UnitSickkids Research Institute and Dalla Lana School of Public HealthUniversity of TorontoTorontoONCanada
| | - AC Allen
- PediatricsIWK Health CenterDalhousie UniversityHalifaxNSCanada
| | - BA Armson
- Obstetrics and GynecologyIWK Health CenterDalhousie UniversityHalifaxNSCanada
| | - A Gafni
- Faculty of Health SciencesMcMaster UniversityHamiltonONCanada
| | - K Mangoff
- Center for Mother, Infant and Child ResearchSunnybrook Research InstituteUniversity of TorontoTorontoONCanada
| | - JJ Sanchez
- Center for Mother, Infant and Child ResearchSunnybrook Research InstituteUniversity of TorontoTorontoONCanada
| | - JF Barrett
- Department of Obstetrics and GynaecologyUniversity of TorontoTorontoONCanada
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Roth DE, Gernand AD, Morris SK, Pezzack B, Islam MM, Dimitris MC, Shanta SS, Zlotkin SH, Willan AR, Ahmed T, Shah PS, Murphy KE, Weksberg R, Choufani S, Shah R, Al Mahmud A. Maternal vitamin D supplementation during pregnancy and lactation to promote infant growth in Dhaka, Bangladesh (MDIG trial): study protocol for a randomized controlled trial. Trials 2015; 16:300. [PMID: 26169781 PMCID: PMC4499946 DOI: 10.1186/s13063-015-0825-8] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2015] [Accepted: 06/26/2015] [Indexed: 12/27/2022] Open
Abstract
Background Vitamin D regulates bone mineral metabolism and skeletal development. Some observational studies have suggested that prenatal vitamin D deficiency increases the risk of adverse pregnancy and/or birth outcomes; however, there is scant evidence from controlled trials, leading the World Health Organization to advise against routine vitamin D supplementation in pregnancy. Importantly, little is known about the effect of maternal vitamin D status on infant linear growth in communities in South Asia where stunting is highly prevalent and maternal-infant vitamin D status is commonly suboptimal. Methods/Design The Maternal Vitamin D for Infant Growth study is a randomized, placebo-controlled, dose-ranging trial of maternal vitamin D supplementation during pregnancy and lactation in Dhaka, Bangladesh. The primary aims are to estimate (1) the effect of maternal prenatal oral vitamin D3 supplementation (4200 IU/wk, 16,800 IU/wk, or 28,000 IU/wk, administered as weekly doses) versus placebo on infant length at 1 year of age and (2) the effect of maternal postpartum oral vitamin D3 supplementation (28,000 IU/wk) versus placebo on length at 1 year of age among infants born to women who received vitamin D 28,000 IU/wk during pregnancy. Generally healthy pregnant women (n = 1300) in the second trimester (17–24 weeks of gestation) are randomized to one of five parallel arms: placebo 4200 IU/wk, 16,800 IU/wk, or 28,000 IU/wk in the prenatal period and placebo in the postpartum period or 28,000 IU/wk in the prenatal period and 28,000 IU/wk in the postpartum period. Household- and clinic-based follow-up of mother-infant pairs is conducted weekly by trained personnel until 26 weeks postpartum and every 3 months thereafter. The primary trial outcome measure is length for age z-score at 1 year of age. Anthropometric measurements, clinical information, and biological specimens collected at scheduled intervals will enable the assessment of a range of maternal, perinatal, and infant outcomes. Discussion The role of vitamin D in maternal and infant health remains unresolved. This trial is expected to contribute unique insights into the effects of improving maternal-infant vitamin D status in a low-income setting where stunting and adverse perinatal outcomes represent significant public health burdens. Trial registration ClinicalTrials.gov identifier: NCT01924013. Registered on 13 August 2013 Electronic supplementary material The online version of this article (doi:10.1186/s13063-015-0825-8) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Daniel E Roth
- Department of Paediatrics, University of Toronto and the Centre for Global Child Health, Hospital for Sick Children, 686 Bay Street, Toronto, ON, Canada. .,Child Health Evaluative Sciences, SickKids Research Institute, Hospital for Sick Children, 686 Bay Street, Toronto, ON, Canada.
| | - Alison D Gernand
- Department of Nutritional Sciences, Penn State University, 110 Chandlee Laboratory, University Park, PA, USA.
| | - Shaun K Morris
- Department of Paediatrics, University of Toronto and the Centre for Global Child Health, Hospital for Sick Children, 686 Bay Street, Toronto, ON, Canada. .,Child Health Evaluative Sciences, SickKids Research Institute, Hospital for Sick Children, 686 Bay Street, Toronto, ON, Canada.
| | - Brendon Pezzack
- Department of Paediatrics, University of Toronto and the Centre for Global Child Health, Hospital for Sick Children, 686 Bay Street, Toronto, ON, Canada. .,Child Health Evaluative Sciences, SickKids Research Institute, Hospital for Sick Children, 686 Bay Street, Toronto, ON, Canada.
| | - M Munirul Islam
- Centre for Nutrition and Food Security, International Centre for Diarrhoeal Disease Research (ICDDR,B), 68 Shaheed Tajuddin Ahmed Sarani, Mohakhali, Dhaka, 1212, Bangladesh.
| | - Michelle C Dimitris
- Department of Paediatrics, University of Toronto and the Centre for Global Child Health, Hospital for Sick Children, 686 Bay Street, Toronto, ON, Canada. .,Child Health Evaluative Sciences, SickKids Research Institute, Hospital for Sick Children, 686 Bay Street, Toronto, ON, Canada.
| | - Shaila S Shanta
- Centre for Nutrition and Food Security, International Centre for Diarrhoeal Disease Research (ICDDR,B), 68 Shaheed Tajuddin Ahmed Sarani, Mohakhali, Dhaka, 1212, Bangladesh.
| | - Stanley H Zlotkin
- Department of Paediatrics, University of Toronto and the Centre for Global Child Health, Hospital for Sick Children, 686 Bay Street, Toronto, ON, Canada. .,Child Health Evaluative Sciences, SickKids Research Institute, Hospital for Sick Children, 686 Bay Street, Toronto, ON, Canada.
| | - Andrew R Willan
- Child Health Evaluative Sciences, SickKids Research Institute, Hospital for Sick Children, 686 Bay Street, Toronto, ON, Canada.
| | - Tahmeed Ahmed
- Centre for Nutrition and Food Security, International Centre for Diarrhoeal Disease Research (ICDDR,B), 68 Shaheed Tajuddin Ahmed Sarani, Mohakhali, Dhaka, 1212, Bangladesh.
| | - Prakesh S Shah
- Department of Paediatrics, University of Toronto and the Centre for Global Child Health, Hospital for Sick Children, 686 Bay Street, Toronto, ON, Canada. .,Division of Neonatology, Mt. Sinai Hospital, 600 University Avenue, Toronto, ON, Canada.
| | - Kellie E Murphy
- Department of Obstetrics and Gynecology, University of Toronto and Mt. Sinai Hospital, 600 University Avenue, Toronto, ON, Canada.
| | - Rosanna Weksberg
- Department of Paediatrics, University of Toronto and the Centre for Global Child Health, Hospital for Sick Children, 686 Bay Street, Toronto, ON, Canada. .,Genetics and Genome Biology, SickKids Research Institute, Hospital for Sick Children, 686 Bay Street, Toronto, ON, Canada.
| | - Sanaa Choufani
- Genetics and Genome Biology, SickKids Research Institute, Hospital for Sick Children, 686 Bay Street, Toronto, ON, Canada.
| | - Rashed Shah
- Department of Health and Nutrition, Save the Children USA, 2000 L Street NW, Suite 500, Washington, DC, USA.
| | - Abdullah Al Mahmud
- Centre for Child and Adolescent Health, International Centre for Diarrhoeal Disease Research (ICDDR,B), 68 Shaheed Tajuddin Ahmed Sarani, Mohakhali, Dhaka, 1212, Bangladesh.
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Parshuram CS, Amaral ACKB, Ferguson ND, Baker GR, Etchells EE, Flintoft V, Granton J, Lingard L, Kirpalani H, Mehta S, Moldofsky H, Scales DC, Stewart TE, Willan AR, Friedrich JO. Patient safety, resident well-being and continuity of care with different resident duty schedules in the intensive care unit: a randomized trial. CMAJ 2015; 187:321-9. [PMID: 25667258 DOI: 10.1503/cmaj.140752] [Citation(s) in RCA: 68] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
BACKGROUND Shorter resident duty periods are increasingly mandated to improve patient safety and physician well-being. However, increases in continuity-related errors may counteract the purported benefits of reducing fatigue. We evaluated the effects of 3 resident schedules in the intensive care unit (ICU) on patient safety, resident well-being and continuity of care. METHODS Residents in 2 university-affiliated ICUs were randomly assigned (in 2-month rotation-blocks from January to June 2009) to in-house overnight schedules of 24, 16 or 12 hours. The primary patient outcome was adverse events. The primary resident outcome was sleepiness, measured by the 7-point Stanford Sleepiness Scale. Secondary outcomes were patient deaths, preventable adverse events, and residents' physical symptoms and burnout. Continuity of care and perceptions of ICU staff were also assessed. RESULTS We evaluated 47 (96%) of 49 residents, all 971 admissions, 5894 patient-days and 452 staff surveys. We found no effect of schedule (24-, 16- or 12-h shifts) on adverse events (81.3, 76.3 and 78.2 events per 1000 patient-days, respectively; p = 0.7) or on residents' sleepiness in the daytime (mean rating 2.33, 2.61 and 2.30, respectively; p = 0.3) or at night (mean rating 3.06, 2.73 and 2.42, respectively; p = 0.2). Seven of 8 preventable adverse events occurred with the 12-hour schedule (p = 0.1). Mortality rates were similar for the 3 schedules. Residents' somatic symptoms were more severe and more frequent with the 24-hour schedule (p = 0.04); however, burnout was similar across the groups. ICU staff rated residents' knowledge and decision-making worst with the 16-hour schedule. INTERPRETATION Our findings do not support the purported advantages of shorter duty schedules. They also highlight the trade-offs between residents' symptoms and multiple secondary measures of patient safety. Further delineation of this emerging signal is required before widespread system change. TRIAL REGISTRATION ClinicalTrials.gov, no. NCT00679809.
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Affiliation(s)
- Christopher S Parshuram
- Department of Critical Care Medicine (Parshuram) and The Center for Safety Research at Child Health Evaluative Sciences (Parshuram, Willan), The Hospital for Sick Children, Toronto, Ont.; Interdepartmental Division of Critical Care Medicine (Parshuram, Amaral, Ferguson, Granton, Mehta, Scales, Friedrich,), Institute for Health Policy, Management and Evaluation (Baker, Flintoft), Department of Medicine (Etchells, Granton, Stewart), Department of Anaesthesia (Stewart) and Dalla Lana School of Public Health (Willan), University of Toronto, Toronto, Ont.; Department of Critical Care (Friedrich) and Li Ka Shing Knowledge Institute (Friedrich), St. Michael's Hospital, Toronto, Ont.; Sunnybrook Research Institute (Amaral, Scales), Department of Critical Care Medicine (Amaral, Scales) and Division of General Internal Medicine (Etchells), Sunnybrook Health Sciences Centre, Toronto, Ont.; Critical Care Medicine (Granton), University Health Network, Toronto, Ont.; Centre for Education Research and Innovation (Lingard) and Department of Medicine and Dentistry (Lingard), Western University, London, Ont.; Perelman School of Medicine (Kirpalani), University of Pennsylvania, Philadelphia, Pa.; Neonatology (Kirpalani), The Children's Hospital of Philadelphia, Philadelphia, Pa.; Department of Medicine, Division of Respirology and Critical Care Program (Ferguson, Mehta), Mount Sinai Hospital and University Health Network, Toronto, Ont.; Department of Medicine, (Mehta) Mount Sinai Hospital, Toronto, Ont.; Sleep Disorders Clinic of the Centre for Sleep and Chronobiology (Moldofsky), Toronto, Ont.; Department of Clinical Epidemiology and Biostatistics (Willan), McMaster University, Hamilton, Ont.; Research Institute (Ferguson), Toronto General Hospital, Toronto, Ont.
| | - Andre C K B Amaral
- Department of Critical Care Medicine (Parshuram) and The Center for Safety Research at Child Health Evaluative Sciences (Parshuram, Willan), The Hospital for Sick Children, Toronto, Ont.; Interdepartmental Division of Critical Care Medicine (Parshuram, Amaral, Ferguson, Granton, Mehta, Scales, Friedrich,), Institute for Health Policy, Management and Evaluation (Baker, Flintoft), Department of Medicine (Etchells, Granton, Stewart), Department of Anaesthesia (Stewart) and Dalla Lana School of Public Health (Willan), University of Toronto, Toronto, Ont.; Department of Critical Care (Friedrich) and Li Ka Shing Knowledge Institute (Friedrich), St. Michael's Hospital, Toronto, Ont.; Sunnybrook Research Institute (Amaral, Scales), Department of Critical Care Medicine (Amaral, Scales) and Division of General Internal Medicine (Etchells), Sunnybrook Health Sciences Centre, Toronto, Ont.; Critical Care Medicine (Granton), University Health Network, Toronto, Ont.; Centre for Education Research and Innovation (Lingard) and Department of Medicine and Dentistry (Lingard), Western University, London, Ont.; Perelman School of Medicine (Kirpalani), University of Pennsylvania, Philadelphia, Pa.; Neonatology (Kirpalani), The Children's Hospital of Philadelphia, Philadelphia, Pa.; Department of Medicine, Division of Respirology and Critical Care Program (Ferguson, Mehta), Mount Sinai Hospital and University Health Network, Toronto, Ont.; Department of Medicine, (Mehta) Mount Sinai Hospital, Toronto, Ont.; Sleep Disorders Clinic of the Centre for Sleep and Chronobiology (Moldofsky), Toronto, Ont.; Department of Clinical Epidemiology and Biostatistics (Willan), McMaster University, Hamilton, Ont.; Research Institute (Ferguson), Toronto General Hospital, Toronto, Ont
| | - Niall D Ferguson
- Department of Critical Care Medicine (Parshuram) and The Center for Safety Research at Child Health Evaluative Sciences (Parshuram, Willan), The Hospital for Sick Children, Toronto, Ont.; Interdepartmental Division of Critical Care Medicine (Parshuram, Amaral, Ferguson, Granton, Mehta, Scales, Friedrich,), Institute for Health Policy, Management and Evaluation (Baker, Flintoft), Department of Medicine (Etchells, Granton, Stewart), Department of Anaesthesia (Stewart) and Dalla Lana School of Public Health (Willan), University of Toronto, Toronto, Ont.; Department of Critical Care (Friedrich) and Li Ka Shing Knowledge Institute (Friedrich), St. Michael's Hospital, Toronto, Ont.; Sunnybrook Research Institute (Amaral, Scales), Department of Critical Care Medicine (Amaral, Scales) and Division of General Internal Medicine (Etchells), Sunnybrook Health Sciences Centre, Toronto, Ont.; Critical Care Medicine (Granton), University Health Network, Toronto, Ont.; Centre for Education Research and Innovation (Lingard) and Department of Medicine and Dentistry (Lingard), Western University, London, Ont.; Perelman School of Medicine (Kirpalani), University of Pennsylvania, Philadelphia, Pa.; Neonatology (Kirpalani), The Children's Hospital of Philadelphia, Philadelphia, Pa.; Department of Medicine, Division of Respirology and Critical Care Program (Ferguson, Mehta), Mount Sinai Hospital and University Health Network, Toronto, Ont.; Department of Medicine, (Mehta) Mount Sinai Hospital, Toronto, Ont.; Sleep Disorders Clinic of the Centre for Sleep and Chronobiology (Moldofsky), Toronto, Ont.; Department of Clinical Epidemiology and Biostatistics (Willan), McMaster University, Hamilton, Ont.; Research Institute (Ferguson), Toronto General Hospital, Toronto, Ont
| | - G Ross Baker
- Department of Critical Care Medicine (Parshuram) and The Center for Safety Research at Child Health Evaluative Sciences (Parshuram, Willan), The Hospital for Sick Children, Toronto, Ont.; Interdepartmental Division of Critical Care Medicine (Parshuram, Amaral, Ferguson, Granton, Mehta, Scales, Friedrich,), Institute for Health Policy, Management and Evaluation (Baker, Flintoft), Department of Medicine (Etchells, Granton, Stewart), Department of Anaesthesia (Stewart) and Dalla Lana School of Public Health (Willan), University of Toronto, Toronto, Ont.; Department of Critical Care (Friedrich) and Li Ka Shing Knowledge Institute (Friedrich), St. Michael's Hospital, Toronto, Ont.; Sunnybrook Research Institute (Amaral, Scales), Department of Critical Care Medicine (Amaral, Scales) and Division of General Internal Medicine (Etchells), Sunnybrook Health Sciences Centre, Toronto, Ont.; Critical Care Medicine (Granton), University Health Network, Toronto, Ont.; Centre for Education Research and Innovation (Lingard) and Department of Medicine and Dentistry (Lingard), Western University, London, Ont.; Perelman School of Medicine (Kirpalani), University of Pennsylvania, Philadelphia, Pa.; Neonatology (Kirpalani), The Children's Hospital of Philadelphia, Philadelphia, Pa.; Department of Medicine, Division of Respirology and Critical Care Program (Ferguson, Mehta), Mount Sinai Hospital and University Health Network, Toronto, Ont.; Department of Medicine, (Mehta) Mount Sinai Hospital, Toronto, Ont.; Sleep Disorders Clinic of the Centre for Sleep and Chronobiology (Moldofsky), Toronto, Ont.; Department of Clinical Epidemiology and Biostatistics (Willan), McMaster University, Hamilton, Ont.; Research Institute (Ferguson), Toronto General Hospital, Toronto, Ont
| | - Edward E Etchells
- Department of Critical Care Medicine (Parshuram) and The Center for Safety Research at Child Health Evaluative Sciences (Parshuram, Willan), The Hospital for Sick Children, Toronto, Ont.; Interdepartmental Division of Critical Care Medicine (Parshuram, Amaral, Ferguson, Granton, Mehta, Scales, Friedrich,), Institute for Health Policy, Management and Evaluation (Baker, Flintoft), Department of Medicine (Etchells, Granton, Stewart), Department of Anaesthesia (Stewart) and Dalla Lana School of Public Health (Willan), University of Toronto, Toronto, Ont.; Department of Critical Care (Friedrich) and Li Ka Shing Knowledge Institute (Friedrich), St. Michael's Hospital, Toronto, Ont.; Sunnybrook Research Institute (Amaral, Scales), Department of Critical Care Medicine (Amaral, Scales) and Division of General Internal Medicine (Etchells), Sunnybrook Health Sciences Centre, Toronto, Ont.; Critical Care Medicine (Granton), University Health Network, Toronto, Ont.; Centre for Education Research and Innovation (Lingard) and Department of Medicine and Dentistry (Lingard), Western University, London, Ont.; Perelman School of Medicine (Kirpalani), University of Pennsylvania, Philadelphia, Pa.; Neonatology (Kirpalani), The Children's Hospital of Philadelphia, Philadelphia, Pa.; Department of Medicine, Division of Respirology and Critical Care Program (Ferguson, Mehta), Mount Sinai Hospital and University Health Network, Toronto, Ont.; Department of Medicine, (Mehta) Mount Sinai Hospital, Toronto, Ont.; Sleep Disorders Clinic of the Centre for Sleep and Chronobiology (Moldofsky), Toronto, Ont.; Department of Clinical Epidemiology and Biostatistics (Willan), McMaster University, Hamilton, Ont.; Research Institute (Ferguson), Toronto General Hospital, Toronto, Ont
| | - Virginia Flintoft
- Department of Critical Care Medicine (Parshuram) and The Center for Safety Research at Child Health Evaluative Sciences (Parshuram, Willan), The Hospital for Sick Children, Toronto, Ont.; Interdepartmental Division of Critical Care Medicine (Parshuram, Amaral, Ferguson, Granton, Mehta, Scales, Friedrich,), Institute for Health Policy, Management and Evaluation (Baker, Flintoft), Department of Medicine (Etchells, Granton, Stewart), Department of Anaesthesia (Stewart) and Dalla Lana School of Public Health (Willan), University of Toronto, Toronto, Ont.; Department of Critical Care (Friedrich) and Li Ka Shing Knowledge Institute (Friedrich), St. Michael's Hospital, Toronto, Ont.; Sunnybrook Research Institute (Amaral, Scales), Department of Critical Care Medicine (Amaral, Scales) and Division of General Internal Medicine (Etchells), Sunnybrook Health Sciences Centre, Toronto, Ont.; Critical Care Medicine (Granton), University Health Network, Toronto, Ont.; Centre for Education Research and Innovation (Lingard) and Department of Medicine and Dentistry (Lingard), Western University, London, Ont.; Perelman School of Medicine (Kirpalani), University of Pennsylvania, Philadelphia, Pa.; Neonatology (Kirpalani), The Children's Hospital of Philadelphia, Philadelphia, Pa.; Department of Medicine, Division of Respirology and Critical Care Program (Ferguson, Mehta), Mount Sinai Hospital and University Health Network, Toronto, Ont.; Department of Medicine, (Mehta) Mount Sinai Hospital, Toronto, Ont.; Sleep Disorders Clinic of the Centre for Sleep and Chronobiology (Moldofsky), Toronto, Ont.; Department of Clinical Epidemiology and Biostatistics (Willan), McMaster University, Hamilton, Ont.; Research Institute (Ferguson), Toronto General Hospital, Toronto, Ont
| | - John Granton
- Department of Critical Care Medicine (Parshuram) and The Center for Safety Research at Child Health Evaluative Sciences (Parshuram, Willan), The Hospital for Sick Children, Toronto, Ont.; Interdepartmental Division of Critical Care Medicine (Parshuram, Amaral, Ferguson, Granton, Mehta, Scales, Friedrich,), Institute for Health Policy, Management and Evaluation (Baker, Flintoft), Department of Medicine (Etchells, Granton, Stewart), Department of Anaesthesia (Stewart) and Dalla Lana School of Public Health (Willan), University of Toronto, Toronto, Ont.; Department of Critical Care (Friedrich) and Li Ka Shing Knowledge Institute (Friedrich), St. Michael's Hospital, Toronto, Ont.; Sunnybrook Research Institute (Amaral, Scales), Department of Critical Care Medicine (Amaral, Scales) and Division of General Internal Medicine (Etchells), Sunnybrook Health Sciences Centre, Toronto, Ont.; Critical Care Medicine (Granton), University Health Network, Toronto, Ont.; Centre for Education Research and Innovation (Lingard) and Department of Medicine and Dentistry (Lingard), Western University, London, Ont.; Perelman School of Medicine (Kirpalani), University of Pennsylvania, Philadelphia, Pa.; Neonatology (Kirpalani), The Children's Hospital of Philadelphia, Philadelphia, Pa.; Department of Medicine, Division of Respirology and Critical Care Program (Ferguson, Mehta), Mount Sinai Hospital and University Health Network, Toronto, Ont.; Department of Medicine, (Mehta) Mount Sinai Hospital, Toronto, Ont.; Sleep Disorders Clinic of the Centre for Sleep and Chronobiology (Moldofsky), Toronto, Ont.; Department of Clinical Epidemiology and Biostatistics (Willan), McMaster University, Hamilton, Ont.; Research Institute (Ferguson), Toronto General Hospital, Toronto, Ont
| | - Lorelei Lingard
- Department of Critical Care Medicine (Parshuram) and The Center for Safety Research at Child Health Evaluative Sciences (Parshuram, Willan), The Hospital for Sick Children, Toronto, Ont.; Interdepartmental Division of Critical Care Medicine (Parshuram, Amaral, Ferguson, Granton, Mehta, Scales, Friedrich,), Institute for Health Policy, Management and Evaluation (Baker, Flintoft), Department of Medicine (Etchells, Granton, Stewart), Department of Anaesthesia (Stewart) and Dalla Lana School of Public Health (Willan), University of Toronto, Toronto, Ont.; Department of Critical Care (Friedrich) and Li Ka Shing Knowledge Institute (Friedrich), St. Michael's Hospital, Toronto, Ont.; Sunnybrook Research Institute (Amaral, Scales), Department of Critical Care Medicine (Amaral, Scales) and Division of General Internal Medicine (Etchells), Sunnybrook Health Sciences Centre, Toronto, Ont.; Critical Care Medicine (Granton), University Health Network, Toronto, Ont.; Centre for Education Research and Innovation (Lingard) and Department of Medicine and Dentistry (Lingard), Western University, London, Ont.; Perelman School of Medicine (Kirpalani), University of Pennsylvania, Philadelphia, Pa.; Neonatology (Kirpalani), The Children's Hospital of Philadelphia, Philadelphia, Pa.; Department of Medicine, Division of Respirology and Critical Care Program (Ferguson, Mehta), Mount Sinai Hospital and University Health Network, Toronto, Ont.; Department of Medicine, (Mehta) Mount Sinai Hospital, Toronto, Ont.; Sleep Disorders Clinic of the Centre for Sleep and Chronobiology (Moldofsky), Toronto, Ont.; Department of Clinical Epidemiology and Biostatistics (Willan), McMaster University, Hamilton, Ont.; Research Institute (Ferguson), Toronto General Hospital, Toronto, Ont
| | - Haresh Kirpalani
- Department of Critical Care Medicine (Parshuram) and The Center for Safety Research at Child Health Evaluative Sciences (Parshuram, Willan), The Hospital for Sick Children, Toronto, Ont.; Interdepartmental Division of Critical Care Medicine (Parshuram, Amaral, Ferguson, Granton, Mehta, Scales, Friedrich,), Institute for Health Policy, Management and Evaluation (Baker, Flintoft), Department of Medicine (Etchells, Granton, Stewart), Department of Anaesthesia (Stewart) and Dalla Lana School of Public Health (Willan), University of Toronto, Toronto, Ont.; Department of Critical Care (Friedrich) and Li Ka Shing Knowledge Institute (Friedrich), St. Michael's Hospital, Toronto, Ont.; Sunnybrook Research Institute (Amaral, Scales), Department of Critical Care Medicine (Amaral, Scales) and Division of General Internal Medicine (Etchells), Sunnybrook Health Sciences Centre, Toronto, Ont.; Critical Care Medicine (Granton), University Health Network, Toronto, Ont.; Centre for Education Research and Innovation (Lingard) and Department of Medicine and Dentistry (Lingard), Western University, London, Ont.; Perelman School of Medicine (Kirpalani), University of Pennsylvania, Philadelphia, Pa.; Neonatology (Kirpalani), The Children's Hospital of Philadelphia, Philadelphia, Pa.; Department of Medicine, Division of Respirology and Critical Care Program (Ferguson, Mehta), Mount Sinai Hospital and University Health Network, Toronto, Ont.; Department of Medicine, (Mehta) Mount Sinai Hospital, Toronto, Ont.; Sleep Disorders Clinic of the Centre for Sleep and Chronobiology (Moldofsky), Toronto, Ont.; Department of Clinical Epidemiology and Biostatistics (Willan), McMaster University, Hamilton, Ont.; Research Institute (Ferguson), Toronto General Hospital, Toronto, Ont
| | - Sangeeta Mehta
- Department of Critical Care Medicine (Parshuram) and The Center for Safety Research at Child Health Evaluative Sciences (Parshuram, Willan), The Hospital for Sick Children, Toronto, Ont.; Interdepartmental Division of Critical Care Medicine (Parshuram, Amaral, Ferguson, Granton, Mehta, Scales, Friedrich,), Institute for Health Policy, Management and Evaluation (Baker, Flintoft), Department of Medicine (Etchells, Granton, Stewart), Department of Anaesthesia (Stewart) and Dalla Lana School of Public Health (Willan), University of Toronto, Toronto, Ont.; Department of Critical Care (Friedrich) and Li Ka Shing Knowledge Institute (Friedrich), St. Michael's Hospital, Toronto, Ont.; Sunnybrook Research Institute (Amaral, Scales), Department of Critical Care Medicine (Amaral, Scales) and Division of General Internal Medicine (Etchells), Sunnybrook Health Sciences Centre, Toronto, Ont.; Critical Care Medicine (Granton), University Health Network, Toronto, Ont.; Centre for Education Research and Innovation (Lingard) and Department of Medicine and Dentistry (Lingard), Western University, London, Ont.; Perelman School of Medicine (Kirpalani), University of Pennsylvania, Philadelphia, Pa.; Neonatology (Kirpalani), The Children's Hospital of Philadelphia, Philadelphia, Pa.; Department of Medicine, Division of Respirology and Critical Care Program (Ferguson, Mehta), Mount Sinai Hospital and University Health Network, Toronto, Ont.; Department of Medicine, (Mehta) Mount Sinai Hospital, Toronto, Ont.; Sleep Disorders Clinic of the Centre for Sleep and Chronobiology (Moldofsky), Toronto, Ont.; Department of Clinical Epidemiology and Biostatistics (Willan), McMaster University, Hamilton, Ont.; Research Institute (Ferguson), Toronto General Hospital, Toronto, Ont
| | - Harvey Moldofsky
- Department of Critical Care Medicine (Parshuram) and The Center for Safety Research at Child Health Evaluative Sciences (Parshuram, Willan), The Hospital for Sick Children, Toronto, Ont.; Interdepartmental Division of Critical Care Medicine (Parshuram, Amaral, Ferguson, Granton, Mehta, Scales, Friedrich,), Institute for Health Policy, Management and Evaluation (Baker, Flintoft), Department of Medicine (Etchells, Granton, Stewart), Department of Anaesthesia (Stewart) and Dalla Lana School of Public Health (Willan), University of Toronto, Toronto, Ont.; Department of Critical Care (Friedrich) and Li Ka Shing Knowledge Institute (Friedrich), St. Michael's Hospital, Toronto, Ont.; Sunnybrook Research Institute (Amaral, Scales), Department of Critical Care Medicine (Amaral, Scales) and Division of General Internal Medicine (Etchells), Sunnybrook Health Sciences Centre, Toronto, Ont.; Critical Care Medicine (Granton), University Health Network, Toronto, Ont.; Centre for Education Research and Innovation (Lingard) and Department of Medicine and Dentistry (Lingard), Western University, London, Ont.; Perelman School of Medicine (Kirpalani), University of Pennsylvania, Philadelphia, Pa.; Neonatology (Kirpalani), The Children's Hospital of Philadelphia, Philadelphia, Pa.; Department of Medicine, Division of Respirology and Critical Care Program (Ferguson, Mehta), Mount Sinai Hospital and University Health Network, Toronto, Ont.; Department of Medicine, (Mehta) Mount Sinai Hospital, Toronto, Ont.; Sleep Disorders Clinic of the Centre for Sleep and Chronobiology (Moldofsky), Toronto, Ont.; Department of Clinical Epidemiology and Biostatistics (Willan), McMaster University, Hamilton, Ont.; Research Institute (Ferguson), Toronto General Hospital, Toronto, Ont
| | - Damon C Scales
- Department of Critical Care Medicine (Parshuram) and The Center for Safety Research at Child Health Evaluative Sciences (Parshuram, Willan), The Hospital for Sick Children, Toronto, Ont.; Interdepartmental Division of Critical Care Medicine (Parshuram, Amaral, Ferguson, Granton, Mehta, Scales, Friedrich,), Institute for Health Policy, Management and Evaluation (Baker, Flintoft), Department of Medicine (Etchells, Granton, Stewart), Department of Anaesthesia (Stewart) and Dalla Lana School of Public Health (Willan), University of Toronto, Toronto, Ont.; Department of Critical Care (Friedrich) and Li Ka Shing Knowledge Institute (Friedrich), St. Michael's Hospital, Toronto, Ont.; Sunnybrook Research Institute (Amaral, Scales), Department of Critical Care Medicine (Amaral, Scales) and Division of General Internal Medicine (Etchells), Sunnybrook Health Sciences Centre, Toronto, Ont.; Critical Care Medicine (Granton), University Health Network, Toronto, Ont.; Centre for Education Research and Innovation (Lingard) and Department of Medicine and Dentistry (Lingard), Western University, London, Ont.; Perelman School of Medicine (Kirpalani), University of Pennsylvania, Philadelphia, Pa.; Neonatology (Kirpalani), The Children's Hospital of Philadelphia, Philadelphia, Pa.; Department of Medicine, Division of Respirology and Critical Care Program (Ferguson, Mehta), Mount Sinai Hospital and University Health Network, Toronto, Ont.; Department of Medicine, (Mehta) Mount Sinai Hospital, Toronto, Ont.; Sleep Disorders Clinic of the Centre for Sleep and Chronobiology (Moldofsky), Toronto, Ont.; Department of Clinical Epidemiology and Biostatistics (Willan), McMaster University, Hamilton, Ont.; Research Institute (Ferguson), Toronto General Hospital, Toronto, Ont
| | - Thomas E Stewart
- Department of Critical Care Medicine (Parshuram) and The Center for Safety Research at Child Health Evaluative Sciences (Parshuram, Willan), The Hospital for Sick Children, Toronto, Ont.; Interdepartmental Division of Critical Care Medicine (Parshuram, Amaral, Ferguson, Granton, Mehta, Scales, Friedrich,), Institute for Health Policy, Management and Evaluation (Baker, Flintoft), Department of Medicine (Etchells, Granton, Stewart), Department of Anaesthesia (Stewart) and Dalla Lana School of Public Health (Willan), University of Toronto, Toronto, Ont.; Department of Critical Care (Friedrich) and Li Ka Shing Knowledge Institute (Friedrich), St. Michael's Hospital, Toronto, Ont.; Sunnybrook Research Institute (Amaral, Scales), Department of Critical Care Medicine (Amaral, Scales) and Division of General Internal Medicine (Etchells), Sunnybrook Health Sciences Centre, Toronto, Ont.; Critical Care Medicine (Granton), University Health Network, Toronto, Ont.; Centre for Education Research and Innovation (Lingard) and Department of Medicine and Dentistry (Lingard), Western University, London, Ont.; Perelman School of Medicine (Kirpalani), University of Pennsylvania, Philadelphia, Pa.; Neonatology (Kirpalani), The Children's Hospital of Philadelphia, Philadelphia, Pa.; Department of Medicine, Division of Respirology and Critical Care Program (Ferguson, Mehta), Mount Sinai Hospital and University Health Network, Toronto, Ont.; Department of Medicine, (Mehta) Mount Sinai Hospital, Toronto, Ont.; Sleep Disorders Clinic of the Centre for Sleep and Chronobiology (Moldofsky), Toronto, Ont.; Department of Clinical Epidemiology and Biostatistics (Willan), McMaster University, Hamilton, Ont.; Research Institute (Ferguson), Toronto General Hospital, Toronto, Ont
| | - Andrew R Willan
- Department of Critical Care Medicine (Parshuram) and The Center for Safety Research at Child Health Evaluative Sciences (Parshuram, Willan), The Hospital for Sick Children, Toronto, Ont.; Interdepartmental Division of Critical Care Medicine (Parshuram, Amaral, Ferguson, Granton, Mehta, Scales, Friedrich,), Institute for Health Policy, Management and Evaluation (Baker, Flintoft), Department of Medicine (Etchells, Granton, Stewart), Department of Anaesthesia (Stewart) and Dalla Lana School of Public Health (Willan), University of Toronto, Toronto, Ont.; Department of Critical Care (Friedrich) and Li Ka Shing Knowledge Institute (Friedrich), St. Michael's Hospital, Toronto, Ont.; Sunnybrook Research Institute (Amaral, Scales), Department of Critical Care Medicine (Amaral, Scales) and Division of General Internal Medicine (Etchells), Sunnybrook Health Sciences Centre, Toronto, Ont.; Critical Care Medicine (Granton), University Health Network, Toronto, Ont.; Centre for Education Research and Innovation (Lingard) and Department of Medicine and Dentistry (Lingard), Western University, London, Ont.; Perelman School of Medicine (Kirpalani), University of Pennsylvania, Philadelphia, Pa.; Neonatology (Kirpalani), The Children's Hospital of Philadelphia, Philadelphia, Pa.; Department of Medicine, Division of Respirology and Critical Care Program (Ferguson, Mehta), Mount Sinai Hospital and University Health Network, Toronto, Ont.; Department of Medicine, (Mehta) Mount Sinai Hospital, Toronto, Ont.; Sleep Disorders Clinic of the Centre for Sleep and Chronobiology (Moldofsky), Toronto, Ont.; Department of Clinical Epidemiology and Biostatistics (Willan), McMaster University, Hamilton, Ont.; Research Institute (Ferguson), Toronto General Hospital, Toronto, Ont
| | - Jan O Friedrich
- Department of Critical Care Medicine (Parshuram) and The Center for Safety Research at Child Health Evaluative Sciences (Parshuram, Willan), The Hospital for Sick Children, Toronto, Ont.; Interdepartmental Division of Critical Care Medicine (Parshuram, Amaral, Ferguson, Granton, Mehta, Scales, Friedrich,), Institute for Health Policy, Management and Evaluation (Baker, Flintoft), Department of Medicine (Etchells, Granton, Stewart), Department of Anaesthesia (Stewart) and Dalla Lana School of Public Health (Willan), University of Toronto, Toronto, Ont.; Department of Critical Care (Friedrich) and Li Ka Shing Knowledge Institute (Friedrich), St. Michael's Hospital, Toronto, Ont.; Sunnybrook Research Institute (Amaral, Scales), Department of Critical Care Medicine (Amaral, Scales) and Division of General Internal Medicine (Etchells), Sunnybrook Health Sciences Centre, Toronto, Ont.; Critical Care Medicine (Granton), University Health Network, Toronto, Ont.; Centre for Education Research and Innovation (Lingard) and Department of Medicine and Dentistry (Lingard), Western University, London, Ont.; Perelman School of Medicine (Kirpalani), University of Pennsylvania, Philadelphia, Pa.; Neonatology (Kirpalani), The Children's Hospital of Philadelphia, Philadelphia, Pa.; Department of Medicine, Division of Respirology and Critical Care Program (Ferguson, Mehta), Mount Sinai Hospital and University Health Network, Toronto, Ont.; Department of Medicine, (Mehta) Mount Sinai Hospital, Toronto, Ont.; Sleep Disorders Clinic of the Centre for Sleep and Chronobiology (Moldofsky), Toronto, Ont.; Department of Clinical Epidemiology and Biostatistics (Willan), McMaster University, Hamilton, Ont.; Research Institute (Ferguson), Toronto General Hospital, Toronto, Ont
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Schuh S, Freedman S, Coates A, Allen U, Parkin PC, Stephens D, Ungar W, DaSilva Z, Willan AR. Effect of oximetry on hospitalization in bronchiolitis: a randomized clinical trial. JAMA 2014; 312:712-8. [PMID: 25138332 DOI: 10.1001/jama.2014.8637] [Citation(s) in RCA: 66] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
IMPORTANCE Routine use of pulse oximetry has been associated with changes in bronchiolitis management and may have lowered the hospitalization threshold for patients with bronchiolitis. OBJECTIVE To examine if infants with bronchiolitis whose displayed oximetry measurements have been artificially elevated 3 percentage points above true values experience hospitalization rates at least 15% lower compared with infants with true values displayed. DESIGN, SETTING, AND PARTICIPANTS Randomized, double-blind, parallel-group trial conducted from 2008 to 2013 in a tertiary-care pediatric emergency department in Toronto, Ontario, Canada. Participants were 213 otherwise healthy infants aged 4 weeks to 12 months with mild to moderate bronchiolitis and true oxygen saturations of 88% or higher. INTERVENTIONS Pulse oximetry measurements with true saturation values displayed or with altered saturation values displayed that have been increased 3 percentage points above true values. MAIN OUTCOMES AND MEASURES The primary outcome was hospitalization within 72 hours, defined as inpatient admission within this interval or active hospital care for greater than 6 hours. Secondary outcomes included the use of supplemental oxygen in the emergency department, level of physician agreement with discharge from the emergency department, length of emergency department stay, and unscheduled visits for bronchiolitis within 72 hours. RESULTS Forty-four of 108 patients (41%) in the true oximetry group and 26 of 105 (25%) in the altered oximetry group were hospitalized within 72 hours (difference, 16% [95% CI for the difference, 3.6% to 28.4%]; P = .005). Using the emergency department physician as a random effect, the primary treatment effect remained significant (adjusted odds ratio, 4.0 [95% CI, 1.6 to 10.5]; P = .009). None of the secondary outcomes were significantly different between the groups. There were 23 of 108 (21.3%) subsequent unscheduled medical visits for bronchiolitis in the true oximetry group and 15 of 105 (14.3%) in the altered oximetry group (difference, 7% [95% CI, -0.3% to 0.2%]; P = .18). CONCLUSIONS AND RELEVANCE Among infants presenting to an emergency department with mild to moderate bronchiolitis, those with an artificially elevated pulse oximetry reading were less likely to be hospitalized within 72 hours or to receive active hospital care for more than 6 hours than those with unaltered oximetry readings. This suggests that oxygen saturation should not be the only factor in the decision to admit, and its use may need to be reevaluated. TRIAL REGISTRATION clinicaltrials.gov Identifier: NCT00673946.
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Affiliation(s)
- Suzanne Schuh
- Department of Pediatrics, The Hospital for Sick Children, Toronto, Ontario, Canada2Research Institute, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Stephen Freedman
- Department of Pediatrics, Alberta Children's Hospital, Calgary, Alberta, Canada
| | - Allan Coates
- Research Institute, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Upton Allen
- Department of Pediatrics, The Hospital for Sick Children, Toronto, Ontario, Canada2Research Institute, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Patricia C Parkin
- Department of Pediatrics, The Hospital for Sick Children, Toronto, Ontario, Canada2Research Institute, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Derek Stephens
- Research Institute, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Wendy Ungar
- Research Institute, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Zelia DaSilva
- Department of Pediatrics, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Andrew R Willan
- Research Institute, The Hospital for Sick Children, Toronto, Ontario, Canada
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Abrahamyan L, Willan AR, Beyene J, Mclimont M, Blanchette V, Feldman BM. Using value-of-information methods when the disease is rare and the treatment is expensive--the example of hemophilia A. J Gen Intern Med 2014; 29 Suppl 3:S767-73. [PMID: 25029970 PMCID: PMC4124117 DOI: 10.1007/s11606-014-2880-3] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
BACKGROUND Hemophilia A is a rare, sex-linked genetic disorder treated with intravenous administration of factor VIII (FVIII) to prevent bleeding; however, approaches vary across and within countries. Value-of-information (VOI) methods identify situations in which the cost-benefit evidence is sufficient to adopt one treatment strategy over another; when the evidence is insufficient, VOI methods provide the optimal sample size for additional research. OBJECTIVE The objective of the study was to use VOI methods in a cost-benefit decision context to evaluate the current evidence in support of using (1) alternate day prophylaxis (AP), (2) tailored prophylaxis (TP) or (3) on-demand treatment (OD) with FVIII to prevent arthropathy in children with severe hemophilia A. METHODS To apply VOI methods, several parameters such as incidence, time horizon for the decision, costs, and threshold values to avoid MRI-detected joint damage or arthropathy were defined. Two baseline threshold values of willingness to pay for avoiding arthropathy--$200,000 and $400,000--were selected for comparing the treatment strategies. RESULTS For threshold values < $200,000, OD had a higher expected net benefit than either prophylaxis strategy, and the evidence was sufficient for its adoption. For threshold values > $400,000 prophylaxis strategies had higher expected net benefit; however, a new trial with 38 patients per arm was needed to compare AP and TP, yielding an expected net gain of over $17 million. In sensitivity analyses, the results were robust to assumptions regarding discount rate, trial fixed and variable costs, enrollment fraction, and the time horizon. CONCLUSIONS In rare diseases, evidence is often scarce and insufficient for decision making. In considering the funding of new research and patient reimbursement in rare diseases, VOI methodology may provide more relevant determinations of the value and costs of additional research, compared to standard frequentist methods.
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Affiliation(s)
- Lusine Abrahamyan
- />Toronto Health Economics and Technology Assessment Collaborative, University of Toronto, Toronto, Ontario Canada
| | - Andrew R. Willan
- />Child Health Evaluative Sciences Program, The SickKids Research Institute, 555 University Avenue, Toronto, Ontario M5G 1X8 Canada
- />The Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario Canada
| | - Joseph Beyene
- />Child Health Evaluative Sciences Program, The SickKids Research Institute, 555 University Avenue, Toronto, Ontario M5G 1X8 Canada
- />The Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario Canada
- />Institute of Health Policy Management and Evaluation, University of Toronto, Toronto, Ontario Canada
- />Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Ontario Canada
- />Division of Hematology/Oncology, The Hospital for Sick Children, Toronto, Ontario Canada
| | - Marjorie Mclimont
- />Child Health Evaluative Sciences Program, The SickKids Research Institute, 555 University Avenue, Toronto, Ontario M5G 1X8 Canada
| | - Victor Blanchette
- />Child Health Evaluative Sciences Program, The SickKids Research Institute, 555 University Avenue, Toronto, Ontario M5G 1X8 Canada
- />Division of Hematology/Oncology, The Hospital for Sick Children, Toronto, Ontario Canada
| | - Brian M. Feldman
- />Child Health Evaluative Sciences Program, The SickKids Research Institute, 555 University Avenue, Toronto, Ontario M5G 1X8 Canada
- />The Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario Canada
- />Institute of Health Policy Management and Evaluation, University of Toronto, Toronto, Ontario Canada
- />Departments of Paediatrics, Division of Rheumatology, The Hospital for Sick Children, Toronto, Ontario Canada
| | - for the Canadian Hemophilia Primary Prophylaxis (CHPS) Study Group
- />Toronto Health Economics and Technology Assessment Collaborative, University of Toronto, Toronto, Ontario Canada
- />Child Health Evaluative Sciences Program, The SickKids Research Institute, 555 University Avenue, Toronto, Ontario M5G 1X8 Canada
- />The Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario Canada
- />Institute of Health Policy Management and Evaluation, University of Toronto, Toronto, Ontario Canada
- />Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Ontario Canada
- />Division of Hematology/Oncology, The Hospital for Sick Children, Toronto, Ontario Canada
- />Departments of Paediatrics, Division of Rheumatology, The Hospital for Sick Children, Toronto, Ontario Canada
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Freedman SB, Williamson-Urquhart S, Schuh S, Sherman PM, Farion KJ, Gouin S, Willan AR, Goeree R, Johnson DW, Black K, Schnadower D, Gorelick MH. Impact of emergency department probiotic treatment of pediatric gastroenteritis: study protocol for the PROGUT (Probiotic Regimen for Outpatient Gastroenteritis Utility of Treatment) randomized controlled trial. Trials 2014; 15:170. [PMID: 24885220 PMCID: PMC4037747 DOI: 10.1186/1745-6215-15-170] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2014] [Accepted: 04/29/2014] [Indexed: 01/01/2023] Open
Abstract
Background The burden of acute gastroenteritis on children and their families continues to be enormous. Probiotics, defined as viable microbial preparations that have a beneficial effect on the health of the host, represent a rapidly expanding field. Although clinical trials in children with gastroenteritis have been performed, most have significant flaws, and guidelines do not consistently endorse their use. Methods/Design PROGUT is a randomized, placebo-controlled, double-blind, five-center, Canadian, emergency department trial. Children aged 3 months to 48 months who present between November 2013 and June 2017 with <72 hours of gastroenteritis symptoms will be assessed for eligibility. A total of 886 children will be randomized (1:1 allocation via an internet based, third party, randomization service) to receive 5 days of a combination probiotic agent (Lactobacillus rhamnosus and L. helveticus) or placebo. All participants, caregivers, and outcome assessors will be blinded to group assignment. The study includes three key outcomes: 1) clinical - the development of moderate to severe disease following an emergency department (ED) evaluation that employs a validated clinical score (Modified Vesikari Scale); 2) safety - side effect; and 3) mechanism - fecal secretory immunoglobulin A levels. Discussion Definitive data are lacking to guide the clinical use of probiotics in children with acute gastroenteritis. Hence, probiotics are rarely prescribed by North American physicians. However, the following current trends obligate an urgent assessment: 1) probiotics are sold as food supplements, and manufacturers can encourage their use while their relevance has yet to be established; 2) North American and European government agencies remain concerned about their value and safety; 3) some institutions are now recommending the routine use of probiotics; and 4) parents of affected children are often providing probiotics. With probiotic consumption increasing in the absence of solid evidence, there is a need to conduct this definitive trial to overcome the limitations of prior work in this field. Trial registration ClinicalTrials.gov: NCT01853124; first registered 9 May 2013.
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Affiliation(s)
- Stephen B Freedman
- Sections of Paediatric Emergency Medicine and Gastroenterology, Alberta Children's Hospital, Alberta Children's Hospital Research Institute, University of Calgary, 2888 Shaganappi Trail NW, Calgary, AB T3B 6A8, Canada.
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Asztalos EV, Willan AR, Matthews SG. More evidence that unnecessary antenatal treatments cause harm--reply. JAMA Pediatr 2014; 168:389-90. [PMID: 24710588 DOI: 10.1001/jamapediatrics.2013.5244] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Affiliation(s)
- Elizabeth V Asztalos
- Department of Newborn and Developmental Paediatrics, Sunnybrook Health Sciences Centre, Sunnybrook Research Institute, University of Toronto, Toronto, Ontario, Canada
| | - Andrew R Willan
- Program in Child Health Evaluative Sciences, SickKids Research Institute, Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
| | - Stephen G Matthews
- Department of Physiology, Fraser Mustard Institute of Human Development, University of Toronto, Toronto, Ontario, Canada4Department of Obstetrics and Gynaecology, Fraser Mustard Institute of Human Development, University of Toronto, Toronto, Ontario, Cana
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Ballantyne M, Stevens B, Guttmann A, Willan AR, Rosenbaum P. Maternal and infant predictors of attendance at Neonatal Follow-Up programmes. Child Care Health Dev 2014; 40:250-8. [PMID: 23294101 DOI: 10.1111/cch.12015] [Citation(s) in RCA: 46] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/16/2012] [Indexed: 11/30/2022]
Abstract
BACKGROUND Neonatal Follow-Up (NFU) programmes provide health services for families of infants at high risk of developmental problems following difficult or extremely premature birth: yet, up to 30% of families do not attend these programmes with their infants. METHODS The study objective was to determine maternal and infant factors that predicted attendance at NFU programmes. Utilizing Andersen's Behavioural Model of Health Services Use, a prospective two-phase multi-site descriptive cohort study was conducted in three Canadian Neonatal Intensive Care Units (NICU) that refer to two affiliated NFU programmes. In Phase 1, 357 mothers completed standardized questionnaires that addressed maternal and infant factors, prior to their infants' NICU discharge. In Phase 2, attendance at NFU was followed at three time points over a 12-month period. Factors of interest included predisposing factors (e.g. demographic characteristics and social context); enabling factors (e.g. social support, travel distance, and income); and infant illness severity (i.e. needs factors). Multivariate logistic regression was used to estimate the odds ratio for each independent factor. RESULTS Mothers parenting alone, experiencing higher levels of worry about maternal alcohol or drug use, or at greater distances from NFU were less likely to attend. Mothers experiencing higher maternal stress at the time of the infant's NICU hospitalization were more likely to attend NFU. No infant factors were predictive of NFU attendance. CONCLUSIONS Mothers at risk of not attending NFU programmes with their infants require better identification, triage, referral and additional support to promote engagement with NFU programmes and improved quality of life for their high-risk infants.
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Affiliation(s)
- M Ballantyne
- School of Nursing, Faculty of Health Sciences, McMaster University, Hamilton, ON, Canada
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Chan KKW, Willan AR, Gupta M, Pullenayegum E. Underestimation of uncertainties in health utilities derived from mapping algorithms involving health-related quality-of-life measures: statistical explanations and potential remedies. Med Decis Making 2014; 34:863-72. [PMID: 24407513 DOI: 10.1177/0272989x13517750] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
OBJECTIVES Mapping algorithms are being developed in increasing numbers to derive health utilities (HUs) from health-related quality-of-life (HRQOL) data. However, the variances of the mapping-derived HUs are observed to be smaller than those of the actual HUs. METHODS Two reasons are proposed: 1) the presence of important unmeasured predictors leading to a high degree of unexplained variance and 2) ignoring that the regression coefficients are random variables themselves. We derive 3 variance estimators of HUs to account for these causes: 1) R (2)-adjusted estimator, 2) parametric estimator, and 3) nonparametric estimator. We tested these estimators using a simulated dataset and a real dataset involving the EQ-5D-3L and University of Washington Quality of Life questionnaire for patients with head and neck cancers. RESULTS The R (2)-adjusted estimator can be used in ordinary least squares (OLS)-based mapping algorithms and requires only the R (2) from the derivation study. The parametric estimator can be used in OLS-based mapping algorithms and requires the mean square error (MSE) and design matrix from the derivation study. The nonparametric estimator can be used in any mapping algorithm and requires leave-one-out cross-validation MSE from the derivation study. In the simulated dataset, all 3 estimators are within 1% of the variance of the actual HUs. In the real dataset, the unadjusted variance was 45% less than the actual variance, while all 3 estimators are within 10% of the actual variance. CONCLUSIONS When conducting cost-utility analyses (CUA) based on mapping algorithms, the variances of derived HUs should be properly adjusted using one of the proposed methods so that the results of the CUAs will correctly characterize uncertainty.
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Affiliation(s)
- Kelvin K W Chan
- Sunnybrook Health Sciences Centre, Division of Medical Oncology, Department of Medicine, Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada (KKWC),Division of Biostatistics, Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada (KKWC, ARW)
| | - Andrew R Willan
- Division of Biostatistics, Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada (KKWC, ARW)
| | - Michael Gupta
- Department of Surgery, McMaster University, Hamilton, Ontario, Canada (MG)
| | - Eleanor Pullenayegum
- Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Ontario, Canada (EP)
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Chen MH, Willan AR. Value of information methods for assessing a new diagnostic test. Stat Med 2014; 33:1801-15. [PMID: 24403241 DOI: 10.1002/sim.6085] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2013] [Revised: 12/10/2013] [Accepted: 12/11/2013] [Indexed: 11/08/2022]
Abstract
Value-of-information methods are applied to assess the evidence in support of a new diagnostic test and, where the evidence is insufficient for decision making, to determine the optimal sample size for future studies. Net benefit formulations are derived under various diagnostic and treatment scenarios. The expressions for the expected opportunity loss of adopting strategies that include the new test are given. Expressions for the expected value of information from future studies are derived. One-sample and two-sample designs, with or without known prevalence, are considered. An example is given.
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Affiliation(s)
- Maggie Hong Chen
- Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada
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Asztalos EV, Murphy KE, Willan AR, Matthews SG, Ohlsson A, Saigal S, Armson BA, Kelly EN, Delisle MF, Gafni A, Lee SK, Sananes R, Rovet J, Guselle P, Amankwah K, Saleem M, Sanchez J. Multiple courses of antenatal corticosteroids for preterm birth study: outcomes in children at 5 years of age (MACS-5). JAMA Pediatr 2013; 167:1102-10. [PMID: 24126948 DOI: 10.1001/jamapediatrics.2013.2764] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
IMPORTANCE A single course of antenatal corticosteroid therapy is recommended for pregnant women at risk of preterm birth between 24 and 33 weeks' gestational age. However, 50% of women remain pregnant 7 to 14 days later, leading to the question of whether additional courses should be given to women remaining at risk for preterm birth. The Multiple Courses of Antenatal Corticosteroids for Preterm Birth Study (MACS) was an international randomized clinical trial that compared multiple courses of antenatal corticosteroids with a single course in women at risk of preterm birth. OBJECTIVE To determine the effects of single vs multiple courses of antenatal corticosteroid therapy on death or neurodevelopmental disability (neuromotor, neurosensory, or neurocognitive/neurobehavioral function) at 5 years of age in children whose mothers participated in MACS. Our secondary aims were to determine the effect on height, weight, head circumference, blood pressure, intelligence, and specific cognitive (visual, spatial, and language) skills. DESIGN, SETTING, AND PARTICIPANTS Cohort follow-up study of children seen between June 2006 and May 2012 at 55 centers. In total, 1724 women (2141 children) were eligible for the study, of whom 1728 children (80.7% of the 2141 eligible children) participated and 1719 children contributed to the primary outcome. INTERVENTION Single and multiple courses of antenatal corticosteroid therapy. MAIN OUTCOMES AND MEASURES The primary outcome was death or survival with a neurodevelopmental disability in 1 of the following domains: neuromotor (nonambulatory cerebral palsy), neurosensory (blindness, deafness, or need for visual/hearing aids), or neurocognitive/neurobehavioral function (abnormal attention, memory, or behavior). RESULTS There was no significant difference between the groups in the risk of death or neurodevelopmental disability: 217 of 871 children (24.9%) in the multiple-courses group vs 210 of 848 children (24.8%) in the single-course group (odds ratio, 1.02 [95% CI, 0.81 to 1.29]; P = .84). CONCLUSIONS AND RELEVANCE Multiple courses, compared with a single course, of antenatal corticosteroid therapy did not increase or decrease the risk of death or disability at 5 years of age. Because of a lack of strong conclusive evidence of short-term or long-term benefits, it remains our opinion that multiple courses not be recommended in women with ongoing risk of preterm birth. TRIAL REGISTRATION clinicaltrials.gov Identifier: NCT00187382.
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Affiliation(s)
- Elizabeth V Asztalos
- Department of Newborn and Developmental Paediatrics, Sunnybrook Health Sciences Centre, Sunnybrook Research Institute, University of Toronto, Toronto, Ontario, Canada
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Barrett JFR, Hannah ME, Hutton EK, Willan AR, Allen AC, Armson BA, Gafni A, Joseph KS, Mason D, Ohlsson A, Ross S, Sanchez JJ, Asztalos EV. A randomized trial of planned cesarean or vaginal delivery for twin pregnancy. N Engl J Med 2013; 369:1295-305. [PMID: 24088091 PMCID: PMC3954096 DOI: 10.1056/nejmoa1214939] [Citation(s) in RCA: 277] [Impact Index Per Article: 25.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
BACKGROUND Twin birth is associated with a higher risk of adverse perinatal outcomes than singleton birth. It is unclear whether planned cesarean section results in a lower risk of adverse outcomes than planned vaginal delivery in twin pregnancy. METHODS We randomly assigned women between 32 weeks 0 days and 38 weeks 6 days of gestation with twin pregnancy and with the first twin in the cephalic presentation to planned cesarean section or planned vaginal delivery with cesarean only if indicated. Elective delivery was planned between 37 weeks 5 days and 38 weeks 6 days of gestation. The primary outcome was a composite of fetal or neonatal death or serious neonatal morbidity, with the fetus or infant as the unit of analysis for the statistical comparison. RESULTS A total of 1398 women (2795 fetuses) were randomly assigned to planned cesarean delivery and 1406 women (2812 fetuses) to planned vaginal delivery. The rate of cesarean delivery was 90.7% in the planned-cesarean-delivery group and 43.8% in the planned-vaginal-delivery group. Women in the planned-cesarean-delivery group delivered earlier than did those in the planned-vaginal-delivery group (mean number of days from randomization to delivery, 12.4 vs. 13.3; P=0.04). There was no significant difference in the composite primary outcome between the planned-cesarean-delivery group and the planned-vaginal-delivery group (2.2% and 1.9%, respectively; odds ratio with planned cesarean delivery, 1.16; 95% confidence interval, 0.77 to 1.74; P=0.49). CONCLUSIONS In twin pregnancy between 32 weeks 0 days and 38 weeks 6 days of gestation, with the first twin in the cephalic presentation, planned cesarean delivery did not significantly decrease or increase the risk of fetal or neonatal death or serious neonatal morbidity, as compared with planned vaginal delivery. (Funded by the Canadian Institutes of Health Research; ClinicalTrials.gov number, NCT00187369; Current Controlled Trials number, ISRCTN74420086.).
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Affiliation(s)
- Jon F R Barrett
- Department of Obstetrics and Gynaecology, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON, Canada.
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Richmond SA, Willan AR, Rothman L, Camden A, Buliung R, Macarthur C, Howard A. The impact of pedestrian countdown signals on pedestrian-motor vehicle collisions: a reanalysis of data from a quasi-experimental study. Inj Prev 2013; 20:155-8. [PMID: 24065777 PMCID: PMC4033273 DOI: 10.1136/injuryprev-2012-040717] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
OBJECTIVE To perform a more sophisticated analysis of previously published data that advances the understanding of the efficacy of pedestrian countdown signal (PCS) installation on pedestrian-motor vehicle collisions (PMVCs), in the city of Toronto, Canada. METHODS This is an updated analysis of the same dataset from Camden et al. A quasi-experimental design was used to evaluate the effect of PCS on PMVC. A Poisson regression analysis, using a one-group comparison of PMVC, pre-PCS installation to post-PCS installation was used, controlling for season and temporal effects. The outcome was the frequency of reported PMVC (January 2000-December 2009). Similar models were used to analyse specific types of collisions defined by age of pedestrian, injury severity, and pedestrian and vehicle action. Incidence rate ratios with 95% CI are presented. RESULTS This analysis included 9262 PMVC, 2760 during or after PCS installation, at 1965 intersections. There was a 26% increase in the rate of collisions, pre to post-PCS installation (incidence rate ratio=1.26, 95% CI 1.11 to 1.42). CONCLUSIONS The installation of PCS at 1965 signalised intersections in the city of Toronto resulted in an increase in PMVC rates post-PCS installation. PCSs may have an unintended consequence of increasing pedestrian-motor vehicle collisions in some settings.
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Affiliation(s)
- Sarah A Richmond
- Child Health Evaluative Sciences, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Andrew R Willan
- Child Health Evaluative Sciences, The Hospital for Sick Children, Toronto, Ontario, Canada Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
| | - Linda Rothman
- Child Health Evaluative Sciences, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Andi Camden
- Child Health Evaluative Sciences, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Ron Buliung
- Department of Geography and Programs in Environment, University of Toronto Mississauga, Mississauga, Ontario, Canada
| | - Colin Macarthur
- Child Health Evaluative Sciences, The Hospital for Sick Children, Toronto, Ontario, Canada Department of Pediatrics, University of Toronto, Toronto, Ontario, Canada
| | - Andrew Howard
- Child Health Evaluative Sciences, The Hospital for Sick Children, Toronto, Ontario, Canada Division of Orthopaedic Surgery, Hospital for Sick Children, Toronto, Ontario, Canada Department of Surgery, University of Toronto, Toronto, Ontario, Canada Department of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
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