British Columbia Children Research Articles

Cost Savings Analysis of Early Extubation Following Congenital Heart Surgery.

The clinical benefit of early extubation following congenital heart surgery has been demonstrated; however, its effect on resource utilization has not been rigorously evaluated. We sought to determine the cost savings of implementing an early extubation pathway for children undergoing surgery for congenital heart disease. We performed a cost savings analysis after implementation of an early extubation strategy among children undergoing congenital heart surgery at British Columbia Children's Hospital (BCCH) over a 2.5-year period. All patients undergoing one of the eight Society of Thoracic Surgeons (STS) benchmark operations, ASD repair, or bidirectional cavopulmonary anastomosis were included in the analysis (n = 370). We compared our data to aggregate STS multi-institutional data from a contemporary cohort. We estimated daily costs for ICU care, ward care, medications, imaging, additional procedures, and allied health care using an administrative database. Direct costs, indirect costs, and cost savings were estimated. Simulation methods, Monte Carlo, and bootstrapping were used to calculate the 95% credible intervals for all estimates. The mean cost savings per procedure was $12,976 and the total estimated cost savings over the study period at BCCH was $4.8million with direct costs accounting for 91% of cost savings. Sensitivity analysis demonstrated a mean cost savings range of $11,934-$14,059 per procedure. Early extubation is associated with substantial cost savings due to reduced hospital resource utilization. Implementation of an early extubation strategy following congenital heart surgery may contribute to improved resource utilization.

Type 1 diabetes outcomes: Does distance to clinic matter?

To access care, pediatric type 1 diabetes (T1D) patients living in British Columbia (BC), Canada, travel to the sole tertiary pediatric hospital (BC Children's Hospital; BCCH), or they receive community care from pediatric endocrinologists and/or pediatricians. We sought to determine whether hemoglobin A1C (HbA1C ) and patient-reported outcomes were associated with (1) distance to clinic and (2) tertiary vs community care. Patients were recruited from T1D clinics across BC. Clinical chart review and patient surveys were completed, including the Diabetes Treatment Satisfaction Questionnaire (DTSQ). Clinic type was categorized as tertiary (BCCH) or community, and the travel time to BCCH was categorized as <1 hour, 1 to 2 hours, or >2 hours. There were 189 participants. Age and duration of T1D were similar across groups. Mean number of visits/year for BCCH groups were 2.23, 2.24, and 2.05 for the <1-hour, 1- to 2-hour, and >2-hour groups, respectively, vs 3.26 for the community group. Adjusted mean difference in HbA1C was +0.65% (95% confidence interval [CI]: 0.15, 1.15) and +0.52% (95% CI: 0.02, 1.02) for the BCCH >2-hour group compared to the BCCH <1-hour group and community groups, respectively. Child DTSQ scores were significantly lower in the BCCH >2-hour group compared to the BCCH <1-hour and community groups. Children traveling >2 hours to T1D clinic at BCCH had significantly higher HbA1C values and lower satisfaction with care vs those traveling <1 hour to BCCH and those receiving community care. Access to care closer to home may benefit glycemic control in children with T1D and improve treatment satisfaction. Future research should determine whether these findings can be replicated in other regions.

Perceptions of the family physician from adolescents and their caregivers preparing to transition to adult care

BackgroundAdolescents with chronic health conditions and/or disabilities (CHC/D’s) often face challenges when transitioning to adult care, which leads to a higher risk of morbidity and mortality. Although it is recommended that establishing the medical home and family physician (FP) attachment prior to transfer will improve health outcomes, there is little evidence or policy surrounding the role of the FP during this transition. This study explores the described use of health services by adolescents with CHC/D’s, as well as the adolescent’s and caregiver’s perceptions of their FP.MethodsParticipants were recruited from the British Columbia Children’s Hospital, Canada and a multi-method phased approach was used. In Phase 1, 84 adolescent and caregiver pairs completed questionnaires asking what medical services they accessed for specific health needs. In Phase 2, another cohort of 21 adolescent and caregiver pairs completed the same questionnaires and were interviewed regarding their perception of their FP.Results96% (n = 81) of adolescents with CHC/D’s in phase 1 had a FP. Thirty four percent (n = 34) of adolescents had not seen their FP in the last 6 months. While adolescents with CHC/D mostly accessed their FP for primary health issues, they frequently also accessed specialists for prescription refills (50%, n = 51), mental health (29%, n = 30) and sexual health (16%, n = 16). While most adolescent/caregiver participants reported positive communication and trust in their FP, some had a poor understanding of the FP’s role in coordinating care.ConclusionAs many adolescents with CHC/D may see their FP infrequently and may not clearly understand their role, opportunities exist for strengthening primary care home attachment as well as adolescent and caregiver literacy around the potential contribution of the FP during and after transfer to adult services. Responsibility for improving care coordination for this population should be ideally shared between FPs and pediatric specialists.

Validating injury burden estimates using population birth cohorts and longitudinal cohort studies of injury outcomes: the VIBES-Junior study protocol

IntroductionTraumatic injury is a leading contributor to the global disease burden in children and adolescents, but methods used to estimate burden do not account for differences in patterns of injury...

Image guided sclerotherapy for the treatment of venous malformations

BackgroundPercutaneous sclerotherapy is the preferred method of treatment for VMs (venous malformations). However, treatment protocols vary, and research on the most effective sclerosant is conflicting. Additionally, there is limited knowledge on the effect of sclerosant volume on treatment outcome. This study aims to determine the outcomes and complications of image-guided sclerotherapy for VMs with respect to sclerosant and sclerosant volume. Towards this, a 10-year retrospective chart review was conducted of patients with VMs treated with sclerotherapy at the Vascular Anomalies Clinic at British Columbia Children’s Hospital.ResultsThirty-four patients with VMs were treated of which 15 had a successful outcome, 13 had a failed outcome, and 6 had additional planned treatments after the study time period. Lesions on the head and neck or classified as type I or II had the highest success rates. Combination therapy with both ethanol and 3% STS (sodium tetradecyl sulphate), and ethanol alone had a higher success rate (64% and 60%) compared to 3% STS (11%). Major complications were most associated with 3% STS (17%) followed by ethanol (9%), and no major complications were found with combination. No relationship between the volume of sclerosant per lesion volume and outcome was found.ConclusionsCombination and ethanol were the most effective sclerosants in terms of highest success rates and lowest complication rates, and sclerosant volume per lesion volume had no effect on outcomes. Future work should aim at studying larger sample sizes to account for the multiple factors that may influence the choice of sclerosant and treatment outcomes.

Induction prednisone dosing for childhood nephrotic syndrome: how low should we go?

Historically, children with nephrotic syndrome (NS) across British Columbia (BC), Canada have been cared for without formal standardization of induction prednisone dosing. We hypothesized that local historical practice variation in induction dosing was wide and that children treated with lower doses had worse relapsing outcomes. This retrospective cohort study included 92 NS patients from BC Children's Hospital (1990-2010). We excluded secondary causes of NS, age < 1year at diagnosis, steroid resistance, and incomplete induction due to early relapse. We explored cumulative induction dose and defined dosing quartiles. Relapsing outcomes above and below each quartile threshold were compared including total relapses in 2years, time to first relapse, and proportions developing frequently relapsing NS (FRNS) or starting a steroid-sparing agent (SSA). Cumulative prednisone was widely distributed with approximated median, 1st, and 3rd quartile doses of 2500, 2000, and 3000mg/m2 respectively. Doses ≤ 2000mg/m2 showed significantly higher relapses (4.2 vs 2.7), shorter time to first relapse (61 vs 175days), and higher SSA use (36 vs 14%) compared to higher doses. Doses ≤ 2500mg/m2 also showed significantly more relapses (3.9 vs 2.2), quicker first relapse (79 vs 208days), and higher FRNS (37 vs 17%) and SSA use (28 vs 11%). Relapsing outcomes lacked statistical difference in ≤ 3000 vs > 3000mg/m2 doses. Results strongly justify our development of a standardized, province-wide NS clinical pathway to reduce practice variation and minimize under-treatment. The lowest induction prednisone dosing threshold to minimize future relapsing risks is likely between 2000 and 2500mg/m2. Further prospective studies are warranted.

Time Trends and Determinants of Fistula in Cleft Patients at BC Children's Hospital, Canada: A Retrospective 18-Year Medical Chart Audit.

To examine the time trends and determinants of palatal fistula in children with different types of cleft at British Columbia's Children's Hospital between 1995 and 2012. A total of 558 medical charts of nonsyndromic patients with cleft lip and palate were eligible for the chart review. The occurrence of primary palatal fistula was assessed at any time throughout the patient's total observation period. Three types of clefts were recorded: unilateral cleft lip and palate (ULCLP), bilateral cleft lip and palate (BLCLP), and isolated cleft palate (ICP). Cleft severity, time period of treatment, type of surgery and surgeon's experience were tested as determinants. Of all 558 patients, 228 had ULCLP, 226 had ICP, and 104 had BLCLP. The combined postoperative palatal fistula rate was 28%. The significant differences in fistula rates related to type of cleft (patients with BLCLP had the highest fistula rates), time period (rates were higher in earlier years than in later years), type of surgery (highest rates were for two-flap palatoplasty), and surgeons with less experience. Almost one quarter of the patients, developed fistula, and fistula incidence declined after 2009. The higher fistula rates were determined by cleft severity, time period of treatment, type of surgery, and surgeon's experience.

Trends in incidence and long-term outcomes of myelomeningocele in British Columbia

Myelomeningocele is typically a disabling condition that results in neurologic, orthopedic, and urologic morbidity. The aim of this study was to examine the trends over time in both incidence and outcomes of myelomeningocele (MMC) in British Columbia (BC). A retrospective chart review was performed of all children with MMC followed in the British Columbia Children's Hospital (BCCH) Spinal Cord Clinic between 1971 and 2016. The incidence of new MMC cases and the long-term outcomes of MMC were compared between two 10-year cohorts. The first cohort comprised children born with MMC between 1971 and 1981, and the second cohort comprised children born with MMC between 1996 and 2006. A total of 309 children with MMC were followed in the BCCH Spinal Cord Clinic between 1971 and 2016. There were 101 and 46 children with MMC in the two-time cohorts, respectively. Between the earlier and later cohorts, there was a significant difference in the following: MMC incidence [2.5/10,000 births vs 1.1/10,000 births, respectively (p = 0.0002)], mortality [18 vs 0% (p = 0.0009)], and the proportion of cases repaired in under 48h [56 vs 98% (p < 0.0001)]. For surviving children, the proportion of children attending special classes was significantly different between the earlier and later cohorts [16 vs 46%, respectively (p = 0.0002)], whereas all other outcome measures, including the proportion with hydrocephalus, kyphoscoliosis, Chiari II surgery, bowel and bladder continence, recreation participation, obesity, and ambulation, were not significantly different. In BC, the incidence of new cases of MMC has decreased between 1971 and 2016, while the probability of survival for these patients has increased. Despite earlier and more universal post-natal repair, long-term outcomes have not improved significantly over time. Future research should focus on developing ways of reducing disability and improving quality of life for MMC patients and their families.

IN CHILDREN WITH FONTAN PHYSIOLOGY, LIVER STIFFNESS IS CORRELATED WITH AGE, TIME SINCE FONTAN COMPLETION AND BIOCHEMICAL MARKERS OF LIVER DISEASE

Liver disease is of growing concern in children and young adults with Fontan physiology. The natural history of liver disease is this patient population is not presently well defined, largely because a definitive diagnosis is reliant on invasive liver biopsy. Non-invasive investigations to detect liver pathology in Fontan patients have not yet been validated. Transient elastography (TE), to assess liver stiffness, is a validated measurement of liver fibrosis in patients a number of chronic liver diseases. This modality may represent a non-invasive method to assess liver fibrosis in pediatric Fontan patients. We hypothesized that TE values would be associated with age and biochemical markers of liver disease in children with Fontan physiology. We prospectively enrolled 60 patients with Fontan physiology at British Columbia Children’s Hospital. All patients underwent comprehensive liver evaluation including liver enzymes (ALT, AST, GGT, ALP), albumin, bilirubin, INR, CBC, abdominal ultrasound, and TE measurement. The AST to platelet ratio index (APRI) was calculated from the laboratory results. Trained personnel obtained TE measurements of liver stiffness using age-specific probes. A total of 86 TE measurements were performed on 60 unique patients with a median age of 11.3 years (interquartile range 7.7-14.7 years, 55% male). There was a significant correlation between liver stiffness and both the time since Fontan completion (rho=0.45, p < 0.001) and age at the time of TE measurement (rho=0.48, p < 0.001). In addition, there was a significant correlation between liver stiffness and laboratory measures of liver health including APRI (rho=0.39, p=0.01), AST (rho=-0.50, p < 0.01), and INR (rho=0.3128, p=0.05). Findings on ultrasound imaging of the liver and spleen did not correlate with liver stiffness. This represents the largest reported cohort of pediatric Fontan patients to undergo TE as part of a comprehensive liver assessment. While liver stiffness is elevated in the early post Fontan period, we found that TE measurements of liver stiffness increased with both age and time from Fontan completion. Furthermore, the rise in liver stiffness over time was also associated with worsening biochemical markers of liver disease. Our results support the notion that liver disease begins in childhood in this population, and that TE measurement of liver stiffness may be a non-invasive method to identify and monitor the progress of liver disease in pediatric Fontan patients.

Clinical Characteristics and Complications of Pediatric Liver Biopsy: A Single Centre Experience

IntroductionPercutaneous liver biopsy (LB) is the gold standard method for evaluation and management of patients with liver disease. The purpose of this study was to characterize pediatric patients undergoing LB at British Columbia Children's Hospital, and to determine the rate and timing of complications following the procedure. Material and methodsThe medical records of all pediat-ric patients who underwent LB during a six-year retrospective study were reviewed to collect demographic and procedure-related data. Results223 LBs were performed, and 179 of these biopsies were percutaneous or transjugular. Elevated liver enzymes and cholestasis together accounted for almost 70% of the indications for LB, and the histological analysis of liver tissue yielded a specific diagnosis in 89 % of the cases. There were no deaths and no major complications related to LB. The most frequent minor complication was pain (59% of LBs) and the other complications were bleeding-related and classified as minor. The vast majority of complications (88%) were recognized within 8 h of the LB. ConclusionsLB is a valuable and safe procedure in pediatric patients with a low rate of complications. Pediatric patients can be discharged home safely should no complications occur within the first 8-12 h after the procedure.

Outpatient Parenteral Antimicrobial Therapy and Judicious Use of Pediatric Emergency Resources.

Pediatric returns to the emergency department (RTED) vary between 3% and 13% of the total ED volume of visits. However, the incidence and contribution of scheduled RTED on pediatric emergency department (PED) utilization is less clear. Antimicrobial stewardship programs on inpatient wards have been shown to improve judicious use of outpatient parenteral antimicrobial therapy (OPAT) in upon discharge. The implementation of such programs in PEDs has yet to be reported. The objectives of this study are to quantify the burden of scheduled RTED for OPAT on PED utilization and to examine how frequently OPAT use are supported by published practice standards for 3 common pediatric infections-cellulitis, pneumonia, and urinary tract infections. We conducted a single-center retrospective cohort study of all visits made to the British Columbia Children's Hospital PED from May 1, 2012, to April 30, 2013. We identified scheduled RTEDs and characterized those associated with OPAT use with regard to their measures of PED utilization and clinical features. Of 3904 RTED visits, 1310 (33.6%) were scheduled, of which 1029 were OPAT related. Among the latter, 749 RTEDs (69%) were for cellulitis, pneumonia, or urinary tract infections. The median length of stay for OPAT-related RTEDs was 2.0 hours. For 75 (24%) of 317 index visits and 213 (28%) of 749 subsequent RTEDs, oral antibiotic therapy would have been an appropriate option and OPAT could have been avoided. Our findings suggest that OPAT poses a sizable burden on PED utilization, with a proportion of them potentially preventable.

Abstract 4890: A pan-cancer analysis framework for incorporating gene expression information into clinical interpretation of pediatric cancer genomic data

Abstract Genomic characterization used in pediatric cancer clinical trials is limited to the detection of somatic mutations and gene fusions in well-characterized cancer genes. However, these approaches do not reveal actionable therapeutic targets for the majority of pediatric cancer patients. Incorporation of gene expression information into clinical genomic analysis is hindered by the lack of appropriate computational methods, designed for single patients rather than patient cohorts. UC Santa Cruz Treehouse Childhood Cancer Initiative (treehousegenomics.soe.ucsc.edu) enables the incorporation of gene expression information into the genomic evaluation of pediatric cancer patients. We leverage large cancer RNA sequencing datasets, including The Cancer Genome Atlas, Therapeutically Applicable Research to Generate Effective Treatments, Medulloblastoma Advanced Genomics International Consortium, International Cancer Genome Consortium, and published research and clinical studies. Through our “pan-cancer analysis”, we compare each prospective tumor’s RNA sequencing and/or mutational profile to over 11,000 uniformly analyzed tumor profiles using our Tumor Map method. Tumor Map visualizes single tumors together with the reference compendium and identifies samples that are most similar to the given tumor based on the gene expression profiles. We also developed a gene expression outlier analysis to identify transcripts that are over expressed in the given tumor. These pan-cancer gene expression analyses are used in conjunction with mutation data to nominate molecular pathways that may be driving the disease in each child, providing useful information to the medical teams. We aim to evaluate this approach in partnership with pediatric cancer clinical genomic trials at Stanford University, UC San Francisco, Children’s Hospital of Orange County, University of Michigan, Children’s Mercy Hospital, and British Columbia Children’s Hospital. The analysis of the first 27 patients at Stanford, most with refractory solid tumors, provided evidence of the potential clinical utility of incorporating gene expression information into the genomic evaluation of pediatric cancer patients. In all cases, we identified candidate driver molecular pathways that could be targeted by existing FDA-approved therapies or therapies available through a clinical trial. The most frequently identified molecular targets were receptor tyrosine kinases and cyclin-dependent kinases. For 3 patients with no treatment options prior to our work, the analysis contributed to treatment decisions. This study provides a framework for incorporating gene expression information into the clinical interpretation of pediatric cancer genomic data. We underscore the importance of releasing the data to the community immediately following generation, so that they may benefit new patients. Citation Format: Olena Morozova, Yulia Newton, Avanthi Tayi Shah, Holly Beale, Du Linh Lam, John Vivian, Isabel Bjork, Theodore Goldstein, Josh Stuart, Sofie Salama, E. Alejandro Sweet-Cordero, David Haussler. A pan-cancer analysis framework for incorporating gene expression information into clinical interpretation of pediatric cancer genomic data [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2017; 2017 Apr 1-5; Washington, DC. Philadelphia (PA): AACR; Cancer Res 2017;77(13 Suppl):Abstract nr 4890. doi:10.1158/1538-7445.AM2017-4890

Abstract LB-338: A critical evaluation of genomic data sharing: Barriers to accessing pediatric cancer genomic datasets: a Treehouse Childhood Cancer Initiative experience

Abstract Genomic data sharing is increasingly recognized as critical to genomic research. The need is acute in pediatric cancer research due to the rarity of pediatric tumor types and paucity of pediatric cancer data, and in translational research to assess the impact of genomic research on human health. However, genomic data sharing is hindered by an absence of standards regarding timing, patient privacy, use agreement standards, and data characterization and quality. At UC Santa Cruz Treehouse Childhood Cancer Initiative (treehousegenomics.soe.ucsc.edu), we examine individual pediatric cancer tumor RNA sequencing profiles against a database of over 11,000 tumor RNA sequencing profiles from public genomic datasets such as The Cancer Genome Atlas, Therapeutically Applicable Research To Generate Effective Treatments, International Cancer Genome Consortium, and Medulloblastoma Advanced Genomics International, and pediatric cancer clinical trials with which we partner, such as those at Stanford University, UC San Francisco, Children’s Hospital of Orange County, and British Columbia Children’s Hospital. For over 18 months, we have worked systematically to enhance the Treehouse dataset by adding pediatric cancer data and presently underrepresented tumor types. The NIH and other leading funding agencies now regularly require grantees to make genomic data generated available to the research community, either post-publication or after an embargo period. We have combed websites and public repositories, searched PubMed, and contacted researchers directly. Finding data requires a mining of literature, often with limited information, and initiating the many different processes for requesting permission for these datasets, with different and often cumbersome data use obligations. The combination of cryptically named datasets, multiple data types and the practice of grouping datasets from multiple papers under a single study accession makes zeroing in on the correct dataset challenging. Downloading the genomic data is time-consuming, such that a dataset of under a 100 files can take up to a week to download under optimal conditions. Matching metadata is inconsistently available, often vague, sparse or error ridden. Only after months of identifying, permissioning for use, committing to use- and sharing-restricting terms, and downloading the genomic and metadata, is it possible to assess the quality, often discovering that data quality is low. We evaluate the barriers to data sharing based on the Treehouse experience and offer guidelines for timing, use agreement standards, and data characterization and quality, to enhance data sharing and outcomes for all pediatric cancer patients. Citation Format: Katrina Learned, Ann Durbin, Robert Currie, Holly Beale, Du Linh Lam, Theodore Goldstein, Sofie R. Salama, David Haussler, Olena Morozova, Isabel Bjork. A critical evaluation of genomic data sharing: Barriers to accessing pediatric cancer genomic datasets: a Treehouse Childhood Cancer Initiative experience [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2017; 2017 Apr 1-5; Washington, DC. Philadelphia (PA): AACR; Cancer Res 2017;77(13 Suppl):Abstract nr LB-338. doi:10.1158/1538-7445.AM2017-LB-338

Adherence to a pediatric diabetic ketoacidosis protocol in children presenting to a tertiary care hospital.

To review adherence to a provincial diabetic ketoacidosis (DKA) protocol and to assess factors associated with intravenous fluid administration and the length time on an insulin infusion. A retrospective chart review was conducted of all DKA admissions to British Columbia Children's Hospital (BCCH) during September 2008 to December 2013. Data collection included diabetes history, estimation of dehydration, insulin and fluid infusion rates, and frequency of laboratory investigations. Markers of adherence included appropriate use of a fluid bolus, normal saline and insulin infusion time, fluid intake and outputs, and the frequency of blood work during the insulin infusion. A log-linear regression model was fitted to assess the factors associated with insulin infusion duration. Of 157 children (median [interquartile range] age: 10.6 years [5.0, 13.8]) hospitalized for DKA, 45% (n = 70) were male, 55% (n = 86) were transferred from other hospitals, and 26% (n = 40) were admitted to intensive care unit. Thirty-five percent of subjects estimated to have mild or moderate dehydration received fluid boluses. In the adjusted analysis, the average duration on DKA protocol was 39% (95% confidence interval [CI]: 12%, 67%) longer for children admitted with severe dehydration (compared to those with mild dehydration). Health care providers' adherence to the BCCH DKA protocol is poor. More severe dehydration at presentation is associated with longer duration of insulin infusion. Further knowledge translation initiatives focused on accurate estimation of volume depletion to ensure appropriate initial fluid resuscitation-as well as careful monitoring during DKA hospitalization-are important, especially in community centers.

Constipation and paediatric emergency department utilization.

Constipation is a common condition in children. Little is known about the acute health care utilization of constipated children, including how many present to the paediatric emergency department (ED), the spectrum of presenting complaints, investigations and treatments used. We conducted a cross-sectional chart review of all 42,875 visits to British Columbia Children's Hospital ED between August 31, 2012 and September 1, 2013. All visits were assessed for a potential diagnosis of constipation and a total of 913 patients were included. We recorded the chief complaints, tests performed and therapies administered in the ED and measures of flow/efficiency including waiting time (WT), length of stay (LOS) and disposition. Constipation-related visits comprised 2.1% of overall visits. Abdominal pain was found to be the most common presenting complaint in 65.6% of patients; however, 11.9% of patients presented with complaints unrelated to the gastrointestinal tract. Abdominal radiographs were obtained in nearly one-third of patients and almost half of the patients received a fleet enema in the ED. Only a quarter of patients were discharged home on longer-term management. Measures of ED flow were similar between groups, with no meaningful difference in WT or LOS. The vast majority of children (99.7%) were discharged home. Constipation can be treated as an out-patient, rather than burdening the paediatric ED unnecessarily. This study demonstrates over utilization of radiologic tests and invasive ED treatments and an under utilization of outpatient medication and dietary counselling that may contribute to unnecessary return ED visits.

A novel treadmill protocol for exercise testing in children: the British Columbia Children’s Hospital protocol

BackgroundExercise testing in children is widely recommended for a number of clinical and prescriptive reasons. Many institutions continue to use the Bruce protocol for treadmill testing; however, with its incremental...

Acute Kidney Injury in Children With Type 1 Diabetes Hospitalized for Diabetic Ketoacidosis

Acute kidney injury (AKI) in children is associated with poor short-term and long-term health outcomes; however, the frequency of AKI in children hospitalized for diabetic ketoacidosis (DKA) has not been previously examined. To determine the proportion of children hospitalized for DKA who develop AKI and to identify the associated clinical and biochemical markers of AKI. This medical record review of all DKA admissions from September 1, 2008, through December 31, 2013, was conducted at British Columbia Children's Hospital, the tertiary pediatric hospital in British Columbia, Canada. Children aged 18 years or younger with type 1 diabetes and DKA and with complete medical records available for data analysis were included (n = 165). All data collection occurred between September 8, 2014, and June 26, 2015. Data analysis took place from August 25, 2015, to June 8, 2016. Acute kidney injury was defined using Kidney Disease/Improving Global Outcomes serum creatinine criteria. Multinomial logistic regression was used to identify potential factors associated with AKI. Of the 165 children hospitalized for DKA, 106 (64.2%) developed AKI (AKI stage 1, 37 [34.9%]; AKI stage 2, 48 [45.3%]; and AKI stage 3, 21 [19.8%]). Two children required hemodialysis. In the adjusted multinomial logistic regression model, a serum bicarbonate level less than 10 mEq/L (compared with ≥10 mEq/L) was associated with a 5-fold increase in the odds of severe (stage 2 or 3) AKI (adjusted odds ratio [aOR], 5.22; 95% CI, 1.35-20.22). Each increase of 5 beats/min in initial heart rate was associated with a 22% increase in the odds of severe AKI (aOR, 1.22; 95% CI, 1.07-1.39). Initial corrected sodium level of 145 mEq/L or greater (compared with 135-144 mEq/L) was associated with a 3-fold increase in the odds of mild (stage 1) AKI (aOR, 3.29; 95% CI, 1.25-8.66). There were no cases of mortality in patients with or without AKI. This study is the first to date to document that a high proportion of children hospitalized for DKA develop AKI. Acute kidney injury was associated with markers of volume depletion and severe acidosis. Acute kidney injury is concerning because it is associated with increased morbidity and mortality as well as increased risk of chronic renal disease, a finding that is especially relevant among children who are already at risk for diabetic nephropathy. Strategies are needed to improve the diagnosis, management, and follow-up of AKI in children with type 1 diabetes.

Associating Physical Activity Levels with Motor Performance and Physical Function in Childhood Survivors of Acute Lymphoblastic Leukemia.

Purpose: This cross-sectional, observational study investigated whether physical activity (PA) levels are associated with motor performance and physical function in children after treatment for acute lymphoblastic leukemia (ALL). Method: Participants aged 8-13 years who had completed treatment for ALL (3-36 months post-treatment) were tested at their oncology long-term follow-up appointment at the British Columbia Children's Hospital. PA level was measured using the Physical Activity Questionnaire for Older Children (PAQ-C). Motor performance was measured using the Bruininks-Oseretsky Test of Motor Proficiency, Second Edition, Short Form (BOT-2 SF), and physical function was measured using the 6-minute walk test (6MWT). Results: Thirteen children completed testing. PAQ-C scores were not associated with BOT-2 SF or 6MWT performance. Eleven children (85%) performed below the norm for the 6MWT. Children with elevated body mass index had poorer 6MWT but similar PAQ-C scores. Conclusion: PA was not found to be associated with motor performance and physical function. Participants who were overweight or obese had poorer 6MWT performance, which may indicate the need for closer monitoring of post-treatment weight status and physical function in the oncology follow-up setting.

Acute kidney injury following spinal instrumentation surgery in children.

AIMTo determine acute kidney in jury (AKI) incidence and potential risk factors of AKI in children undergoing spinal instrumentation surgery.METHODSAKI incidence in children undergoing spinal instrumentation surgery at British Columbia Children’s Hospital between January 2006 and December 2008 was determined by the Acute Kidney Injury Networ classification using serum creatinine and urine output criteria. During this specific time period, all patients following spinal surgery were monitored in the pediatric intensive care unit and had an indwelling Foley catheter permitting hourly urine output recording. Cases of AKI were identified from our database. From the remaining cohort, we selected group-matched controls that did not satisfy criteria for AKI. The controls were matched for sex, age and underlying diagnosis (idiopathic vs non-idiopathic scoliosis).RESULTSThirty five of 208 patients met criteria for AKI with an incidence of 17% (95%CI: 12%-23%). Of all children who developed AKI, 17 (49%) developed mild AKI (AKI Stage 1), 17 (49%) developed moderate AKI (Stage 2) and 1 patient (3%) met criteria for severe AKI (Stage 3). An inverse relationship was observed with AKI incidence and the amount of fluids received intra-operatively. An inverse relationship was observed with AKI incidence and the amount of fluids received intra-operatively classified by fluid tertiles: 70% incidence in those that received the least amount of fluids vs 29% that received the most fluids (> 7.9, P = 0.02). Patients who developed AKI were more frequently exposed to nephrotoxins (non steroidal anti inflammatory drugs or aminoglycosides) than control patients during their peri-operative course (60% vs 22%, P < 0.001).CONCLUSIONWe observed a high incidence of AKI following spinal instrumentation surgery in children that is potentially related to the frequent use of nephrotoxins and the amount of fluid administered peri-operatively.

Anaphylaxis across two Canadian pediatric centers: evaluating management disparities.

BackgroundThere are no data on the percentage of visits due to anaphylaxis in the emergency department (ED), triggers, and management of anaphylaxis across different provinces in Canada.ObjectiveTo compare the percentage of anaphylaxis cases among all ED visits, as well as the triggers and management of anaphylaxis between two Canadian pediatric EDs (PEDs).MethodsAs part of the Cross-Canada Anaphylaxis Registry (C-CARE), children presenting to the British Columbia Children’s Hospital (BCCH) and Montreal Children’s Hospital (MCH) EDs with anaphylaxis were recruited. Characteristics, triggers, and management of anaphylaxis were documented using a standardized data entry form. Differences in demographics, triggers, and management were determined by comparing the difference of proportions and 95% confidence interval.ResultsBetween June 2014 and June 2016, there were 346 visits due to anaphylaxis among 93,730 PED visits at the BCCH ED and 631 anaphylaxis visits among 164,669 pediatric visits at the MCH ED. In both centers, the majority of cases were triggered by food (BCCH 91.3% [88.7, 94.0], MCH 82.4% [79.7, 85.3]), of which peanuts were the most common culprit (24.7% [20.9, 29.9] and 19.0% [15.8, 22.7], respectively). Pre-hospital administration of epinephrine (BCCH 27.7% [23.2, 32.8], MCH 33.1% [29.5, 37.0]) and antihistamines (BCCH 50.6% [45.2, 56.0], MCH 47.1% [43.1, 51.0]) was similar. In-hospital management differed in terms of increased epinephrine, antihistamine, and steroid use at the BCCH (59.2% [53.9, 64.4], 59.8% [54.4, 65.0], and 60.1% [54.7, 65.3], respectively) compared to the MCH (42.2% [38.3, 46.2], 36.2% [32.5, 40.1], and 11.9% [9.5, 14.8], respectively). Despite differences in management, percentage of cases admitted to the intensive care unit was similar between the two centers.ConclusionCompared to previous European and North American reports, there is a high percentage of anaphylaxis cases in two PEDs across Canada with substantial differences in hospital management practices. It is crucial to develop training programs that aim to increase epinephrine use in anaphylaxis.