Centre Hospitalier Universitaire Sainte-Justine Research Articles

Effects of a Virtual Reality Game on Children's Anxiety During Dental Procedures (VR-TOOTH): Protocol for a Pilot Randomized Controlled Trial.

Dental fear and anxiety (DFA) is a condition that affects approximately one-quarter of children and adolescents. It is a significant cause for pediatric patients to avoid dental care later in adulthood. Lack of patient cooperation due to DFA can create an environment of stress, often obligating dentists to end appointments prematurely and consider alternative pharmacological treatment options. Virtual reality (VR) use during dental care, providing an immersive experience through sensory stimuli, is potentially an additional nonpharmacologic tool to better manage DFA in children with special health care needs (SHCN) undergoing dental procedures. This pilot study aims to assess the feasibility and acceptability of VR immersion as a tool to reduce DFA in pediatric special needs patients undergoing dental procedures. The study also aims to gain insight on parent and health care provider perspectives on the use of VR during dental appointments. This pilot randomized controlled trial study will follow a parallel design including 2 groups: a control group (clinic's standard care using a wall TV) and an experimental group (using a VR game). We will randomize 20 participants to either group. Recruitment will be carried out at the dental clinic of the Centre Hospitalier Universitaire Sainte-Justine, a tertiary-quaternary care center that mostly serves pediatric patients with SHCN. The primary outcome will be patient recruitment rates and completion rates of planned procedures. DFA in children will be assessed using both an observation-based proxy assessment with the Venham Anxiety and Behavior Rating Scale and physiological assessments using parameters such as change in heart rate and levels of salivary alpha-amylase as a stress biomarker before and 10 minutes after the procedure. Sociodemographic characteristics, measures of the levels of parent and health care professional satisfaction, occurrence of side effects, and any deviation from normal procedure length will also be collected. Descriptive statistics, nonparametric tests, and effect sizes will be used for demographic and clinical variables and to present parent and health care professional satisfaction levels as well as procedural time. This study will be conducted from May 2023 to May 2024, with results expected to be available in December 2024. The pilot study will provide insight on the feasibility and acceptability of VR use in clinical dentistry to reduce DFA for pediatric patients with SHCN. This study will guide future research on VR use in pediatric dentistry and can serve as a framework for a larger randomized clinical trial. ClinicalTrials.gov NCT05898100; https://classic.clinicaltrials.gov/ct2/show/NCT05898100. DERR1-10.2196/49956.

19 Characterization of Neurodevelopmental Comorbidities within a Paediatric Population with a First Epileptic Seizure

Abstract Background Epilepsy is the most common paediatric neurological disorder. An estimated 4% of the general population will have an unprovoked epileptic seizure at least once in their lifetime. Of these, about 40% will experience a recurrence within two years. The International League Against Epilepsy (ILAE) established that one part of the definition of epilepsy was the onset of a first seizure with a recurrence risk of more than 60% over 10 years. However, except for epileptiform abnormalities and a structural-metabolic etiology present on the electroencephalogram (EEG), very few known factors are consistently associated with first epileptic seizures. Objectives Our study’s objective was to characterize neurodevelopmental comorbidities, namely attention-deficit hyperactivity disorder (ADHD), autism spectrum disorder (ASD), anxiety, depression, gross motor delay and language delay, in patients following a first epileptic seizure as compared to healthy controls. Design/Methods Children referred in neurology for a first suspected epileptic seizure, between June 2016 and June 2018 at the Centre Hospitalier Universitaire Sainte-Justine (CHUSJ), underwent EEG and neurological evaluations. For screening of comorbidities, parents completed age-appropriate M-CHAT-R/F, SCQ, ASQ-3, SCARED, and CES-DC questionnaires via a web platform adapted from CHADIS. Questionnaire scores were adjusted for age and sex and analyzed via a Student’s t-test. The prevalence of comorbidities was analyzed via a chi-square statistical test. Results A total of 72 subjects aged between 1 month and 18 years (42 males, 30 females) were enrolled in the study. Patients with a first epileptic seizure (n=37) showed significantly more comorbidities compared to the healthy subjects (54% vs. 31%, p<0.05). Patients with a first epileptic seizure had significantly more language delay (50%, p=0.015), ADHD (45%, p=0.008), and a significantly higher score in the Social Communication Questionnaire (SCQ) (p=0.03), compared to healthy subjects. Conclusion Our results confirm the increased rate of comorbidities in children with a first epileptic seizure and, thus, the importance of concomitant screening for those disorders at the time of the initial presentation.

Impact of Unmet Social Needs, Scarcity, and Future Discounting on Adherence to Treatment in Children With Asthma: Protocol for a Prospective Cohort Study

Asthma is one of the most prevalent chronic diseases of childhood and disproportionately affects children with lower socioeconomic status. Controller medications such as inhaled corticosteroids significantly reduce asthma exacerbations and improve symptoms. However, a large proportion of children still have poor asthma control, in part owing to suboptimal adherence. Financial barriers contribute to hindering adherence, as do behavioral factors related to low income. For example, unmet social needs for food, lodging, and childcare may create stress and worry in parents, negatively influencing medication adherence. These needs are also cognitively taxing and force families to focus on immediate needs, leading to scarcity and heightening future discounting; thus, there is the tendency to attribute greater value to the present than to the future in making decisions. In this project, we will investigate the relationship between unmet social needs, scarcity, and future discounting as well as their predictive power over time on medication adherence in children with asthma. This 12-month prospective observational cohort study will recruit 200 families of children aged 2 to 17 years at the Asthma Clinic of the Centre Hospitalier Universitaire Sainte-Justine, a tertiary care pediatric hospital in Montreal, Canada. The primary outcome will be adherence to controller medication, measured using the proportion of prescribed days covered during follow-up. Exploratory outcomes will include health care use. The main independent variables will be unmet social needs, scarcity, and future discounting, measured using validated instruments. These variables will be measured at recruitment as well as at 6- and 12-month follow-ups. Covariates will include sociodemographics, disease and treatment characteristics, and parental stress. Primary analysis will compare adherence to controller medication, measured using the proportion of prescribed days covered, between families with versus those without unmet social needs during the study period using multivariate linear regression. The research activities of this study began in December 2021. Participant enrollment and data collection began in August 2022 and are expected to continue until September 2024. This project will allow the documentation of the impact of unmet social needs, scarcity, and future discounting on adherence in children with asthma using robust metrics of adherence and validated measures of scarcity and future discounting. If the relationship between unmet social needs, behavioral factors, and adherence is supported by our findings, this will suggest the potential for novel targets for integrated social care interventions to improve adherence to controller medication and reduce risk across the life course for vulnerable children with asthma. ClinicalTrials.gov NCT05278000; https://clinicaltrials.gov/ct2/show/NCT05278000. PRR1-10.2196/37318.

Isolated rhinorrhea in the presentation of SARS-CoV-2 infection among preschool- versus school-aged children.

ObjectivesRapid identification and isolation of SARS-CoV-2 cases are priorities in school and child care settings to prevent further outbreaks. The objective of this study was to compare the clinical presentation of SARS-CoV-2 infections among preschool (<5 years) versus school-aged (≥5 years) children diagnosed with SARS-CoV-2 infection, and, specifically, the probability of presenting with an isolated symptom, such rhinorrhea or sore throat.MethodsRetrospective study of children (≤18 years of age) diagnosed with SARS-CoV-2 in the outpatient COVID-19 clinic or the Emergency Department at the Centre Hospitalier Universitaire Sainte-Justine (Montreal, Quebec, Canada) February through May 2020.ResultsOf 3,789 children tested, 105 (3%) were positive for SARS-CoV-2, and 104 included in the analysis (n=49 age <5 years and n=55 age ≥5 years). While fever was the most common presenting symptom across both age groups, in the absence of fever, the presence of a combination of two or more symptoms identified the majority (92%) of cases. Isolated single symptom presentations were uncommon (<5% of cases). Most importantly, not a single child in either age group presented with isolated rhinorrhea or sore throat.ConclusionsWhile there are differences in the clinical manifestations of COVID-19 in preschool- versus school-aged children, in both age groups, isolated rhinorrhea was not a manifestation of SARS-CoV-2 infection. These results could help further guide testing criteria and exclusion criteria in child care and school settings.

Mifepristone-Misoprostol Use for Second- and Third-Trimester Medical Termination of Pregnancy in a Canadian Tertiary Care Centre

ObjectiveThis study aims to evaluate the impact of the implementation a mifepristone-misoprostol protocol (MIFE/MISO) on the induction-to-expulsion interval in the context of second- and third-trimester pregnancy termination or intrauterine fetal death (IUFD) compared with misoprostol alone (MISO), and to share the experience of a Canadian tertiary hospital concerning the feasibility and safety of such a protocol. MethodsThis is a single-centre retrospective pre–post cohort study carried out at the Centre Hospitalier Universitaire (CHU) Sainte-Justine between 2017 and 2019. Women in the MIFE/MISO group were instructed to take mifepristone 24-48 hours before induction. Induction in the MIFE/MISO group was performed with misoprostol dosages adjusted to gestational age and the presence of previous uterine scars, while, in the MISO group, all patients received 400 μg of misoprostol vaginally every 4 hours. ResultsNinety-four patients were included in the MIFE/MISO group and 103 patients, in the MISO group. Median time to expulsion was significantly lower in the MIFE/MISO group than the MISO group (13.5 and 19.5 h respectively; P < 0.001). The total dose of misoprostol administered was significantly lower in the MIFE/MISO group than the MISO group, and adverse effects were reported in 60% and 82% of patient records, respectively (P < 0.001). Complication rates were similar between the 2 groups. ConclusionThe MIFE/MISO protocol is highly effective for second- and third-trimester induction for pregnancy termination or IUFD, without increasing complication rates and with fewer reported adverse effects. Its implementation is safe and feasible in a tertiary medical centre.

PICU Follow-Up Clinic: Patient and Family Outcomes 2 Months After Discharge.

Hospitalization in a PICU is a life-altering experience for children and their families. Yet, little is known about the well-being of these children after their discharge. We are describing the outcome of PICU survivors at a PICU clinic 2 months after discharge. Prospective cohort study. PICU and PICU clinic of CHU Sainte-Justine. Prospective cohort study of children admitted for greater than or equal to 4 days, greater than or equal to 2 days of invasive ventilation, odds ratio greater than or equal to 4 days of noninvasive ventilation at Centre Hospitalier Universitaire Sainte-Justine. Prospective cohort study of children admitted for greater than or equal to 4 days, greater than or equal to 2 days of invasive ventilation, or greater than or equal to 4 days of noninvasive ventilation at Centre Hospitalier Universitaire Sainte-Justine PICU. None. Patients were evaluated by a pediatric intensivist 2 months after discharge at the follow-up clinic. They were asked to fill out validated questionnaires. One hundred thirty-two patients were followed from October 2018 to September 2020. The PICU diagnoses were respiratory illness (40.9%), head trauma, and septic shock (7.6%). Average length of PICU stay was 28.5 ± 84.2 days (median 7 d). Sixty-one percent were intubated. Symptoms reported by families were as follows: fatigue (9.9%), sleep disturbances (20.5%), feeding difficulties (12.1%), and voice change and/or stridor (9.8%). Twenty-one percent of school-aged children reported school delays. Twenty-seven children demonstrated communication delays, 45% gross motor function delays, 41% fine motor delays, 37% delays in problem-solving, and 49% delays in personal-social functioning. Quality of Life scores were 78.1 ± 20.5 and 80.0 ± 17.5 for physical and psychosocial aspects, respectively. Fourteen percent of parents reported financial difficulties, 42% reported symptoms of anxiety, 29% symptoms of depression. PICU survivors and their families experience significant physical and psychosocial morbidities after their critical illness. PICU follow-up is crucial to determine the outcome of these children and develop interventions.

Intravenous Immunoglobulin Use In Critically Ill Children.

Purpose: The use of intravenous immunoglobulins (IVIG) has increased significantly in the last decade causing challenges for blood suppliers to respond to the demand. Indications for which IVIG infusion should be given to critically ill children remain unclear. The objective of this study is to characterize the epidemiology of IVIG use in this population. Methods: We performed a single-center retrospective cohort study of all patients aged between 3 days and 18 years who received at least one IVIG infusion while hospitalized in the pediatric intensive care unit of the Centre hospitalier universitaire (CHU) Sainte-Justine, Montréal Quebec (Canada) between January 1, 2013 and December 31, 2018. Results: One hundred and seventy-two patients received a total of 342 IVIG infusions over the study period. Most common indications for IVIG infusions were staphylococcal or streptococcal toxic shock syndrome (n=53/342, 15.5%), immunoglobulin replacement in chylothorax (n=37/342, 10.9%), prophylaxis following bone marrow transplantation (n=31/342, 9.1%), myocarditis (n=25/342, 7.3%) and post-solid organ transplant complications (n=21/342, 6.1%). The median dose of IVIG per infusion was 0.95 g/kg (IQR 0.5-1.0) and median number of IVIG infusions per patient was one (IQR: 1-2). Seventy-nine percent of IVIG infusions given were administrated for off-label indications with regards to Health Canada recommendations. Conclusion: This study identified the most common indications for IVIG infusion in critically ill children in a tertiary care pediatric intensive care unit. Given the costs, the known adverse events associated with IVIG and the pressure that blood suppliers are facing to meet the demands, clinical trials are needed to evaluate the efficacy and safety of IVIG in conditions where use is significant.

Ultra-short echo-time magnetic resonance imaging lung segmentation with under-Annotations and domain shift.

Ultra-short echo-time (UTE) magnetic resonance imaging (MRI) provides enhanced visualization of pulmonary structural and functional abnormalities and has shown promise in phenotyping lung disease. Here, we describe the development and evaluation of a lung segmentation approach to facilitate UTE MRI methods for patient-based imaging. The proposed approach employs a k-means algorithm in kernel space for pair-wise feature clustering and imposes image domain continuous regularization, coined as continuous kernel k-means (CKKM). The high-order CKKM algorithm was simplified through upper bound relaxation and solved within an iterative continuous max-flow framework. We combined the CKKM with U-net and atlas-based approaches and comprehensively evaluated the performance on 100 images from 25 patients with asthma and bronchial pulmonary dysplasia enrolled at Robarts Research Institute (Western University, London, Canada) and Centre Hospitalier Universitaire (Sainte-Justine, Montreal, Canada). For U-net, we trained the network five times on a mixture of five different images with under-annotations and applied the model to 64 images from the two centres. We also trained a U-net on five images with full and brush annotations from one centre, and tested the model on 32 images from the other centre. For an atlas-based approach, we employed three atlas images to segment 64 target images from the two centres through straightforward atlas registration and label fusion. We applied the CKKM algorithm to the baseline U-net and atlas outputs and refined the initial segmentation through multi-volume image fusion. The integration of CKKM substantially improved baseline results and yielded, with minimal computational cost, segmentation accuracy, and precision that were greater than some state-of-the-art deep learning models and similar to experienced observer manual segmentation. This suggests that deep learning and atlas-based approaches may be utilized to segment UTE MRI datasets using relatively small training datasets with under-annotations.

Seroprevalence of Anti-SARS-CoV-2 Antibodies Among School and Daycare Children: Baseline Results From a Cohort Study in Montreal, Canada

Background: Montreal was one of the highest COVID-19 burdened cities in Canada during the first and second waves of the pandemic. We estimated the seroprevalence of SARS-CoV-2 in children and teenagers in four neighbourhoods of Montreal, Canada.Methods: All children attending selected schools and daycares within the four neighbourhoods were invited to participate in the study. Study participation included an online questionnaire that parents completed, followed by at-home dried blood spot (DBS) collection. Serological results were analyzed using a research-based ELISA assay. Statistical analyses included multivariable logistic regression models to calculate average marginal effects and robust standard errors to account for clustering by school or daycare. Several different sociodemographic differences were examined between the seronegative and seropositive children.Findings: There were 30 daycares, 22 primary schools, and 11 secondary schools that participated in the study with 1,632 participants having provided a DBS sample that was of sufficient quality for the serological analysis. The average seroprevalence was 5·8% (95%CI 4·6 to 7·0) but increased over time from 3·2% (95% CI 0·7 to 5·8) in October-November 2020 to 8.4% (95% CI 4·4 to 12·4) in March-April 2021. The children of visible minority parents were nearly twice as likely to be seropositive as children of non-visible minority parents (1·93, 95%CI 1·11 to 2·75). Interpretation: Our results provide a benchmark of the seroprevalence status in Canadian children and provide further evidence of COVID-19 inequities. It will be important to continue monitoring the serological status of children, particularly in the context of new COVID-19 variants of concern and in the absence of mass vaccination campaigns targeting young children.Funding Information: Public Health Agency of Canada through the COVID-19 Immunity Task Force.Declaration of Interests: All authors declare no competing interests.Ethics Approval Statement: All participants provided informed consent for the survey and ethics approval was received from the research ethics boards of the Université de Montréal and the Centre Hospitalier Universitaire Sainte-Justine.

Implementation of a Computerized Provider Order Entry System in a Pediatric Hospital in Canada.

The Centre Hospitalier Universitaire Sainte-Justine (Montreal, Canada) is a pediatric academic tertiary hospital that has begun the implementation of a commercial computerized provider order entry system (CPOE) in October 2019. The objectives of this paper are 1) to estimate the impact of the CPOE system on medication errors, and 2) to identify vulnerability issues related to the configuration of the CPOE system's design. Using a pre-post implementation methodology measuring medication errors captured by clinical pharmacists revealed that the implementation of a CPOE has eliminated all prescription conformity (e.g., missing fields) and legibility errors. Pharmacists have continued to detect medication errors, especially inappropriate dosing instructions, and to intervene in similar clinical situations (medication reconciliation, deprescribing, adjusting orders). Additionally, the vulnerability analysis, based on typical clinical order test cases in an inpatient pediatric setting, highlighted the need to configure a clinical decision support system that can identify inappropriate dosing instructions for pediatric patients.

Results of the First Pilot Randomized Controlled Trial of Fecal Microbiota Transplant In Pediatric Ulcerative Colitis: Lessons, Limitations, and Future Prospects

Results of the First Pilot Randomized Controlled Trial of Fecal Microbiota Transplant In Pediatric Ulcerative Colitis: Lessons, Limitations, and Future Prospects

Decreasing Pain and Fear in Medical Procedures with a Pediatric Population (DREAM): A Pilot Randomized Within-Subject Trial

BackgroundMany children with injuries, including burns and fractures, experience moderate to severe pain during medical procedures. Recent studies claim that nonpharmacologic pain management using virtual reality (VR) could distract children from procedural pain by engaging multiple senses. AimsThe aims of this pilot randomized clinical trial were to assess the acceptability and feasibility of VR distraction in children with burns or fractures undergoing painful medical procedures, as well as the staff nurses, and assess the preliminary efficacy of VR distraction on pain intensity, pain-related fear, and subsequent recall of both. Materials and MethodA within-subject study design, in which participants served as their own control, was used. A total of 20 children from 7 to 17 years old with an injury were recruited at the surgical-trauma outpatient clinics of the Centre hospitalier universitaire Sainte-Justine (CHU Sainte-Justine). Each participant received both standard and experimental treatments through randomized order. Pain (numerical rating scale) and pain-related fear (Children's Fear Scale) measures were taken before the procedure and after each sequence, followed by a measure of children's (graphic rating scale) and nurses' acceptability of the intervention through their satisfaction level. Recall of pain intensity and pain-related fear were assessed 24 hours after the procedure. Wilcoxon signed-rank tests were used, with a significance level at 0.05. ResultsResults showed that VR distraction was an acceptable and feasible intervention for children and nurses of these outpatient clinics. Preliminary effects showed that, compared to standard of care, children participants reported a significant decrease in pain intensity (p = .023) and pain-related fear (p = .011) during VR as well as less recalled pain-related fear (p = .012) at 24 hours after the procedure. No side effects were reported. ConclusionVR is a promising intervention with children undergoing painful procedures because it is immersive and engages multiple senses. It is a low-cost intervention well accepted by children and nursing staff at this clinical site and is easy to implement in daily practice for procedural pain management.

Stability of Methadone Hydrochloride for Injection in Saline Solution

Until October 2014, methadone hydrochloride for injection (10 mg/mL) was available in Canada through Health Canada's Special Access Programme. Diluted to 5 mg/mL in saline, it was used in pediatrics for acute and cancer-related pain. More recently, the department of pharmacy of the Centre hospitalier universitaire Sainte-Justine in Montréal, Quebec, proposed compounding a solution of methadone hydrochloride for injection (5 mg/mL) from bulk powder and saline solution for pediatric administration. To assess the stability of the proposed compounded preparation. Solutions of methadone hydrochloride in saline were prepared from bulk powder and stored in clear glass vials for up to 180 days at room temperature (25 °C) or with refrigeration (5 °C), with testing on days 0, 7, 14, 30, 60, 90, and 180. The appearance of the solutions and presence of particulate matter were assessed. A stability-indicating high-performance liquid chromatography (HPLC) method was developed to assay the concentration of methadone over time. No notable changes in appearance of the methadone solution were observed, particle counts did not exceed limits specified by the United States Pharmacopeia, and no microbial growth was observed. The HPLC analysis showed that the concentration of methadone remained above 90% on all study days. Methadone hydrochloride for injection prepared from bulk powder in saline solution at a concentration of 5 mg/mL remained chemically stable for at least 180 days when stored in clear glass vials at 5 °C and at 25 °C.

Long-Term Risk Factors for Dilatation of the Proximal Aorta in a Large Cohort of Children With Bicuspid Aortic Valve.

Patients with bicuspid aortic valve (BAV) have a higher risk of developing aortic valve dysfunction and progressive proximal aorta dilatation, which can lead to aortic dissection. To this day, identification of children at risk of developing severe aortic dilatation during their pediatric follow-up is still challenging because most studies were restricted to adult subjects. The overarching goal of this study was to identify risk factors of aortic dilatation in children with BAV. We extracted clinical and echocardiographic data of all BAV subjects aged 0 to 20 years followed at Centre Hospitalier Universitaire Sainte-Justine between 1999 and 2016. We excluded subjects with concomitant heart defects and conditions affecting proximal aorta dimensions. Proximal aorta diameters (expressed as Z scores) were modeled in relation to age and potential predictive variables in a linear mixed model. The primary outcome was the rate of dilatation. We included 761 subjects (3134 echocardiograms) in final analyses. The mean ascending aorta Z score progression rate for BAV patient with a normally functioning aortic valve was estimated at 0.05 Z score unit per year. The strongest predictors of an increased dilatation rate were severe aortic stenosis, moderate and severe aortic regurgitation, and uncorrected coarctation of the aorta. Aortic valve leaflet fusion pattern and sex were not associated with progression rate. Children with a normally functioning BAV exhibited a very slow proximal aorta dilatation rate. Ascending aorta dilatation rate was significantly increased in patients with more than mild aortic valve dysfunction but was independent from BAV leaflet fusion type.

115. Results of a Targeted Neonatal Screening Program for Congenital Cytomegalovirus Infection in Montreal, Quebec

BackgroundThere remains considerable debate on the role of symptomatic, targeted vs. universal screening of newborns for congenital cytomegalovirus infection (cCMV). Here we report on a hospital-based targeted screening program for (1) infants who failed their newborn hearing screen and (2) infants of HIV-infected women, and compare this to the prevalence among infants tested for CMV following clinical suspicion of a congenital infection.MethodsIn November 2013, the “Programme québécois de dépistage de la surdité chez les nouveau-nés” (PQDSN), a provincially mandated hearing screening program, was implemented at Centre Hospitalier Universitaire Sainte-Justine, a tertiary maternal-child health center in Montreal, Quebec, along with CMV screening for all infants who failed their hearing test (excluding patients in the neonatal intensive care unit). Concurrently, beginning in April 2013, all infants of HIV-infected women were screened for cCMV infection within 48 hours of birth. The birth prevalence of cCMV infection in these targeted populations was compared with the prevalence among newborns tested for a clinical suspicion of cCMV.ResultsOut of 11 734 newborns screened for hearing through the PQDSN program between April 2014 and March 2018, 536 failed their initial hearing screen and 4 of these newborns tested positive for cCMV infection (0.75%). Out of a total of 130 HIV-exposed newborns born during this period, 116 were screened for cCMV and 3 (2.6%) confirmed positive. An additional 455 newborns were identified by the attending pediatrician as having a risk factor for any congenital infection; of these, 22 (5.3%) tested positive for cCMV. Using these combined methods, a total of 0.24% of newborns enrolled in the PQDSN program tested positive for cCMV infection.ConclusionThe overall birth prevalence of cCMV was 0.75% among infants who failed their hearing screen, 2.6% among HIV exposed newborns, and 5.3% among infants with a clinical suspicion of a congenital infection. In the absence of a universal screening program for newborns, these results reinforce the importance of maintaining a high index of clinical suspicion for cCMV infection.Disclosures All authors: No reported disclosures.

Clinical characteristics of pediatric pertussis cases, Quebec 2015-2017.

BackgroundThe introduction of the acellular pertussis vaccine may have changed the epidemiological and clinical features of pertussis in Canadian children.ObjectiveTo describe the demographics, clinical presentation and outcomes of children and adolescents with pertussis presenting to a tertiary care hospital.MethodsRetrospective cohort of consecutive patients evaluated at the Centre Hospitalier Universitaire Sainte-Justine (CHUSJ) and tested with a bacterial multiplex real-time polymerase chain reaction (PCR) for Bordetella pertussis or B. parapertussis between June 2015 and March 2017. Demographics, clinical presentations and outcomes were described for positive test results. The Modified Preziosi Scale was used to assess disease severity; severe disease was defined as a score ≥7.ResultsThe age distribution of the 144 positive patients with a clinical encounter at CHUSJ was as follows: less than three months (n=25/144, 17.4%), four months to nine years (n=63/144, 43.8%) and 10 to 18 years (n=56/144, 38.9%). The most common symptoms at presentation were paroxysmal cough (70.1%), post-tussive emesis (47.2%) and coryza (33.3%). Over 84.0% of cases in infants less than three months of age had severe pertussis (92.0% required hospitalization and 28.0% intensive care admission). In children four months to nine years of age, 22.2% had severe pertussis and 11.1% required hospitalization. Only two (3.6%) children greater than 10 years had severe disease.ConclusionPertussis still affects children of all ages in Quebec. In older children, it tends to be a milder disease. When it affects infants, who do not yet have full protection from pertussis vaccination, it often causes severe disease, especially in those less than three months of age. This evidence further supports the implementation of a pertussis vaccination program in pregnant women.

Should equivocal Bordetella pertussis PCR results in children be reported to public health?

Real-time polymerase chain reaction (PCR) is the preferred method for the diagnosis of pertussis. In Quebec, positive and equivocal results are reportable to public health; in contrast, in Ontario equivocal results are not reportable. To determine the clinical significance of equivocal, compared with positive results, in children with suspected pertussis. Retrospective cohort of consecutive patients seen at the Centre Hospitalier Universitaire Sainte-Justine in Montréal, Quebec, with suspected pertussis and tested with a bacterial multiplex PCR (including Bordetella pertussis) between 2015 and 2017. Medical records were reviewed using a standardized form. Univariate analyses (Student's t-test and chi-square test) and multivariable logistic regression were used to compare cases of positive and equivocal results. Of the 1,526 multiplex PCR performed, 109 were positive and 24 equivocal. Both groups were similar in terms of demographics and disease severity assessments, but patients in the equivocal group had less paroxysmal cough (33.3% vs 79.8%, adjusted odds ratio [aOR] 0.11, 95% confidence interval [CI] 0.04-0.29) and whoop (0% vs 18.3%, p<0.001), lower lymphocyte counts (6.6 vs 11.9 x109/L, p=0.008), were more likely to be diagnosed with a viral co-infection (16.7% vs 3.7%, aOR 5.62, 95% CI 1.17-27.54) and were less likely to receive a macrolide (25% vs 89%, aOR 0.04, 95% CI 0.01-0.11). When admitted, patients with equivocal results had a shorter average length of stay (3.3 vs 12.2 days, p=0.001). Although there were similarities in disease severity, children with suspected pertussis who had equivocal PCR results had significantly different clinical presentations compared with those with positive results. In the context of limited public health resources, these results may inform the decision whether or not equivocal results need to be reported to public health by laboratories.

Use of Cytomegalovirus-Specific Hyperimmunoglobulins in Pregnancy: A Retrospective Cohort.

There is no consensus on the use of cytomegalovirus (CMV)-specific hyperimmunoglobulins (CSHIGs) for suspected congenital CMV infections during pregnancy, but this therapy is currently used in some countries. The objectives of this study were to describe tolerability and pregnancy outcome following treatment with monthly intravenous CSHIG and compare rates of positive PCR and postnatal symptoms according to whether CSHIGs were given or not. This retrospective cohort study included all pregnant women who were diagnosed with primary CMV infection or congenital CMV infection at the Centre Hospitalier Universitaire Sainte-Justine (Montreal, QC) between 2005 and 2016. CSHIG was discussed with pregnant women who received positive CMV PCR results from amniotic fluid or if ultrasound anomalies suggested congenital infection and there was serologic evidence of maternal primary infection (therapeutic group). CSHIG was also offered as prophylaxis in pregnant women without fetal ultrasound anomalies but with evidence of maternal primary infection, when amniocentesis either had negative results or was not performed (prophylactic group). A matched analysis was performed to control for timing of maternal infection, amniocentesis, and type and timing of ultrasound anomaly. Sixteen women received CSHIG, and 55 had no CMV-specific treatment. CSHIG treatment was well-tolerated. In bivariate analyses, the risk of congenital CMV infection and postnatal symptoms did not significantly decrease with CSHIG treatment, in both the therapeutic and the prophylactic groups. After matching, there was still no difference in outcomes between CSHIG-treated and untreated women. The effectiveness of CSHIG in preventing congenital CMV infection and its clinical manifestations could not be demonstrated.

Identifying domains of quality of life in children with cancer undergoing palliative care: A qualitative study with professionals.

The goal of pediatric palliative care (PPC) is to maintain the quality of life (QoL) of children whose lives are threatened. However, there are sparse scientific data on the domains of QoL in this particular context, and no measurement strategies are available. The present study aims to describe the domains of QoL in the context of PPC in oncology, according to the perceptions of professional caregivers. Semistructured interviews were conducted with a random sample of 20 professional caregivers from the Division of Hematology/Oncology at Le Centre Hospitalier Universitaire Sainte-Justine (Montréal, Canada). The caregivers were asked about their perceptions about the QoL of the children they have cared for in this context. The data were analyzed using inductive thematic content analysis. The analysis allowed us to identify seven domains of QoL: "physical comfort," "alleviation of psychological suffering," "fun and the present moment," "sense of control," "feeling valued and appreciated," "feeling that life goes on," and "meaningful social relationships." Caregivers recount the regard that should be accorded to maintaining well-being and a sense of fun, as well as fostering the child's abilities, taking account of the progression of the disease, and to fulfilling his or her needs, especially social ones. Our results also demonstrate that all domains were positively referred to by professional caregivers. The data from our study will lead to better assessment of QoL according to the trajectory of a child with advanced cancer while undergoing PPC.

Risk factors for pre-term birth in a Canadian cohort of HIV-positive women: role of ritonavir boosting?

BackgroundThe risk of pre-term birth (PTB) associated with the use of protease inhibitors (PIs) during pregnancy remains a subject of debate. Recent data suggest that ritonavir boosting of PIs may play a specific role in the initiation of PTB, through an effect on the maternal–fetal adrenal axis. The primary objective of this study is to compare the risk of PTB among women treated with boosted PI versus non-boosted PIs during pregnancy.MethodsBetween 1988 and 2011, 705 HIV-positive women were enrolled into the Centre Maternel et Infantile sur le SIDA mother–infant cohort at Centre Hospitalier Universitaire Sainte-Justine in Montreal, Canada. Inclusion criteria for the study were: 1) attendance at a minimum of two antenatal obstetric visits and 2) singleton live birth, at 24 weeks gestational or older. The association between PTB (defined as delivery at <37 weeks gestational age), antiretroviral drug exposure and maternal risk factors was assessed retrospectively using logistic regression.ResultsA total of 525 mother–infant pairs were included in the analysis. Among them, PI-based combination anti-retroviral therapy was used in 37.4%, boosted PI based in 24.4%, non-nucleoside reverse transcriptase inhibitor (NNRTI) or nucleoside reverse transcriptase inhibitor based in 28.1%, and no treatment was given in 10.0% of cases. Overall, 13.5% of women experienced PTB. Among women treated with antiretroviral therapy, the risk of PTB was significantly higher among women who received boosted versus non-boosted PI (OR 2.01, 95% CI 1.02–3.97). This remained significant after adjusting for maternal age, delivery CD4 count, hepatitis C co-infection, history of previous PTB, and parity (aOR 2.17, 95% CI 1.05–4.51). There was no increased risk of PTB with the use of unboosted PIs as compared to NNRTI- or NRTI-based regimens.ConclusionWhile previous studies on the association between PTB and PI use have generally considered all PIs the same, our results would indicate a possible role of ritonavir boosting as a risk factor for PTB. Further work is needed to understand the pathophysiologic mechanisms involved, and to identify the safest ARV regimens to be used in pregnancy.