Montreal Children's Hospital Research Articles

Urgent action on antimicrobial resistance

Urgent action on antimicrobial resistance

Daily outpatient intravenous antibiotic therapy for the management of paediatric periorbital cellulitis, a retrospective case series.

To evaluate whether outpatient treatment of periorbital cellulitis with daily administration of intravenous antibiotics and physician evaluation is an effective and safe alternative to admission. A retrospective chart review study of paediatric patients treated on an outpatient basis for periorbital cellulitis at a tertiary children's hospital between 2013 and 2015 was performed. Children were assessed day by a paediatrician to monitor for resolution of symptoms or complications. The Montreal Children's hospital, a tertiary care centre. Children diagnosed with an uncomplicated periorbital cellulitis secondary to an acute sinusitis or upper respiratory tract infection. The number of days of intravenous antibiotics, complications or need for subsequent admission. Complications were defined as formation of an abscess or phlegmon confirmed on computerised tomography scan, worsening or recurrent persistent cellulitis, failure to improve on intravenous antibiotics, and intracranial complications. Sixty-six children with a diagnosis of uncomplicated periorbital cellulitis secondary to sinusitis who received intravenous antibiotics via medical day hospital and who fit the inclusion criteria were identified. The mean duration of intravenous antibiotic therapy was 4.1days. All children received ceftriaxone, with one patient also receiving cefuroxime. Two of 66 patients developed complications; one patient required admission for failure to improve/subperiosteal phlegmon and later underwent functional endoscopic sinus surgery, and one patient developed an eyelid abscess that did not require admission. No patients developed severe neurological or visual deficits. Outpatient intravenous therapy with daily reassessment by a physician may be a safe alternative to admission in select cases of periorbital cellulitis without systemic signs of illness.

Dystonia in RNA Polymerase III-Related Leukodystrophy.

To identify the prevalence of dystonia in a RNA Polymerase III (POLR3)-related leukodystrophy patient cohort and to further characterize their dystonic features. POLR3-related leukodystrophy is a hypomyelinating leukodystrophy characterized by neurological and non-neurological features. Dystonia remains a challenging and under-recognized feature. A retrospective chart review was performed in a cohort of 20 patients for whom videos of a standardized neurological examination were available. Patients were recruited at the Montreal Children's Hospital of the McGill University Health Center and the Myelin Disorders Bioregistry Project. Families were consented at the initial assessment and the following data was recorded: age and symptoms at clinical presentation, investigations, causal gene and mutation(s), type and severity of dystonia, and treatment response when needed. Standardized examination videos were reviewed by three independent reviewers and scored using the Global Dystonia Scale. 10 males and 10 females were included in this study; 12/20 had POLR3A mutations, while 8/20 had POLR3B mutations; 19/20 patients had documented dystonia, with 3/19 requiring therapy. There was a good response in two patients to a single agent, and a poor response in one patient to three agents; the majority had mild-to-moderate multifocal dystonia without a functional impact. Dystonia is a common, yet underdiagnosed, slowly progressive manifestation of POLR3-related leukodystrophy, and in most cases has limited-to-no functional impact. When treatment is needed, good response to typically used medication may occur. Further studies are needed to assess evolution of dystonia over time, patients' functional outcome, and response to therapy (when needed).

PO610 The Natural History of Subclinical Rheumatic Heart Disease: Experience From North India

Significant pulmonary regurgitation, declining right-sided ejection fraction, increased right ventricular (RV) volumes as well as left ventricular (LV) dysfunction have all been identified as predictors of poor outcomes in patients with congenital heart disease (CHD). The prognostic value of the cardiac output (CO) in these patients however has never been studied.All consecutive ambulatory adult patients with CHD referred for magnetic resonance imaging (MRI) at the Montreal Children's Hospital between June 2007 and May 2009 were included. Right ventricular (RV) and left ventricular (LV) variables including end diastolic and end systolic volumes (EDV, ESV respectively), ejection fractions (EF) and regurgitant volumes were obtained. Cardiac index (CI) was calculated. Patients were followed for cardiac-related hospitalizations and cardiac interventions.Ninety-six patients were included. Median follow up was 3.9 ± 1.4 years. Nineteen percent of patients had a systemic CI < 2.4 l/min/m2. LVEDV, LVEF and RVEF were significantly diminished in the low CI group with a significant increase in RVESV and total regurgitant volume. Best predictors of low CI were LVEF (AUC = 0.74), RVEF (AUC = 0.71), total RV regurgitant volume (AUC = 0.64) and RVESV (AUC = 0.563). Low systemic CI was the best predictor of cardiac-related hospitalizations (hazard ratio 3.5, 95% confidence interval 1.5–8.5) and cardiac interventions (hazard ratio 2.2, 95% confidence interval 1.3–4.0), superior to LVEF, RVEF, total regurgitant volume and RVESV parameters.In patients with congenital heart disease, cardiac index is the best predictor of cardiac hospitalizations and cardiac interventions.

Parent-report instruments for assessing feeding difficulties in children with neurological impairments: a systematic review.

This study aimed to review the psychometric properties and clinical application of parent-report instruments that assess feeding difficulties in children with neurological impairments. Papers were identified through five electronic databases based on 15 keywords and were included if they met the following criteria: published in English, described the implementation of parent-report instruments, and included children with neurological impairments (either in the report or a related study population). In total, 1220 relevant abstracts were screened and 22 full-text articles were evaluated. The following six parent-report instruments met the inclusion criteria: (1) Screening Tool of Feeding Problems applied to children, (2) Paediatric Eating Assessment Tool, (3) Paediatric Assessment Scale for Severe Feeding Problems, (4) Montreal Children's Hospital Feeding Scale, (5) Children's Eating Behaviour Inventory, and (6) Behavioural Paediatric Feeding Assessment Scale (BPFAS). Based on comprehensive psychometric testing and consistently good results, the BPFAS was considered the most valid and reliable instrument. The BPFAS also showed good clinical applicability because it was readily available, required a short administration time, and used a simple scoring system. We reviewed the available parent-report instruments for assessing feeding difficulties in children with neurological impairments. The BPFAS had the best psychometric properties and clinical applicability. Six parent-report instruments were suitable for assessing feeding in children with neurological impairments. The Behavioural Paediatric Feeding Assessment Scale (BPFAS) has the strongest psychometric properties. The BPFAS also has good clinical applicability.

The Role of Liver Biopsy in Investigation of Cholestatic Liver Disease in Infancy.

ObjectivesThe objective of this study was to assess the diagnostic yield and impact on management of liver biopsy in infants with cholestatic jaundice.MethodsA retrospective cohort study of infants with cholestasis who underwent liver biopsy before one year of age between December 2002 and December 2013 at the Montreal Children’s Hospital was conducted. Biopsies were reviewed by a single pathologist. The diagnostic yield of the biopsy was assessed in terms of its role in establishing a diagnosis, excluding an important diagnosis or changing management.ResultsSeventy-nine biopsies were performed within the time frame outlined, with 58 fulfilling inclusion criteria. Liver biopsies were found to add novel information in 21 cases (36.2%). The diagnostic yield of the biopsy was unrelated to the severity of direct hyperbilirubinemia, age at biopsy, age at admission, co-morbidities, stool color at presentation and TPN exposure. Among infants under 90 days of age, 21 also underwent cholangiography, the results of which were consistent with biopsy findings. There were four (6.9%) documented complications from biopsies, including bleeding and accumulation of free fluid in the peri-hepatic area.ConclusionsLiver biopsy is an invasive test used with other clinical modalities to determine the etiology of neonatal cholestasis. These results suggest that biopsy added novel information to the diagnostic workup in 36.2% of cases with a complication rate of 6.9%. Consequently, the role and timing of liver biopsy need to be reassessed to determine which patients would most benefit from this procedure.

Measuring feeding difficulties in toddlers with Down syndrome

Early feeding problems occur frequently across the population, but have a higher incidence in children with Down syndrome (DS). Early identification can possibly be improved with the help of a valid screening instrument based on caregiver reports. In a previous study, we investigated the concurrent validity of the Dutch version of the Montreal Children's Hospital Feeding Scale (MCH-FS, SEP in Dutch) in a sample of typically developing toddlers, and we found a correlation between the score on the instrument and observed behavior during a regular meal. The current pilot study was a replication in a sample of children with DS (aged 1; 0–3; 0) and their primary caregivers (n = 32).The results showed that children in the sample did not score higher on the SEP than children in their respective norm groups. In addition, when caregivers reported more symptoms of feeding problems on the SEP, children showed more food refusal and negative affect during the observed meal. This suggests that the screening instrument is particularly associated with negative mealtime interactions. This is in contrast with earlier results, which mainly indicated a relation with eating skills.

The Montreal Children’s Hospital Feeding Scale: Relationships with parental report of child eating behaviours and observed feeding interactions

Feeding problems are common, with implications for nutrition, growth and family stress, placing burden on primary care services. The Montreal Children's Hospital Feeding Scale (MCHFS) is a quick and reliable measure of feeding problems for clinical settings, but there is little examination of its relationship to commonly used research measures of parental feeding practice, child eating behaviour and observations of parent-infant interaction at mealtimes. We examined the relationships between the MCHFS, demographics and early feeding history, weight across the first year, parental report of feeding practices and child eating behaviours, and observations of maternal-infant feeding interaction at 1 year. The MCHFS, Comprehensive Feeding Practices Questionnaire (CFPQ) and Child Eating Behaviour Questionnaire (CEBQ) were completed by 69 mothers when their infants were 1-year-old (37 male, 32 female). Infant weight was measured at 1 week, 1 month, 6 months and 1 year. Mothers were observed feeding their infants at 1 year. The MCHFS was reliable (Cronbach's alpha = .90) and showed significant overlap with other measures of feeding and eating. Potential feeding problems were identified in 10 of the children (14%) reflecting similar rates in other community samples. Higher MCHFS scores were associated with lower birthweight and weight across the first year, greater satiety responsiveness, fussiness and slowness in eating, lower enjoyment of food and food responsiveness, and less observed infant food acceptance. Parents of infants with more feeding problems reported less encouragement of balance and variety in their children's diets. Conclusion: MCHFS showed good criterion validity with other parental report measures of eating and observations of mealtime interactions. MCHFS may be a useful tool for researching feeding problems in community samples.

The obese-asthma phenotype in children: An exacerbating situation?

Current evidence regarding the relationship between childhood obesity, decreased response to inhaled corticosteroids (ICSs), and poor asthma control is conflicting. We assessed whether obesity (1) is associated with time to first exacerbation among children with asthma initiating step 3 maintenance therapies and (2) modifies the effectiveness of step 3 therapies. A retrospective cohort study was conducted from clinical data linked to health and drug administrative databases. The cohort consisted of children aged 2 to 18years with specialist-confirmed asthma who initiated medium/high-dose ICS monotherapy or low/medium-dose ICS with leukotriene receptor antagonist/long-acting β-agonist (combination therapy) at the Montreal Children's Hospital Asthma Center from 2000 to 2007. Children were classified as exposed to step 3 therapies when they were dispensed a corresponding drug claim during follow-up, whereas those without claims were classified as nonadherers. Marginal structural Cox models were used to estimate the effect of obesity (body mass index>97th percentile) and treatment on time to exacerbation, which was defined as any emergency department visit, hospitalization, or use of oral corticosteroids for asthma. Of the 4621 cohort patients, 231 initiated ICS monotherapy, and 97 initiated combination therapy. The hazard ratio (HR) for obesity was 1.67 (95% CI, 1.41-1.98). Compared with nonobese nonadherers, the HR for obese nonadherers was 1.54 (95% CI, 0.97-2.45); the HR for ICS monotherapy in obese and nonobese children was 0.85 (95% CI, 0.47-1.52) and 0.58 (95% CI, 0.37-0.91), respectively; and the HR for combination therapy in obese and nonobese children was 0.50 (95% CI, 0.13-1.89) and 0.46 (95% CI, 0.23-0.92), respectively. Obesity might be a determinant of shorter exacerbation-free time in children with asthma; however, we could not rule out a differential response to step 3 therapies by obesity status, potentially because of a lack of precision.

Outpatient management of pediatric acute mastoiditis

ObjectiveEvaluate the Montreal Children's Hospital experience with outpatient management of uncomplicated acute mastoiditis with parenteral antibiotic therapy alone and determine if it is a safe alternative to inpatient management. Subjects and methodA retrospective review of pediatric patients diagnosed with acute mastoiditis at a tertiary care pediatric hospital between 2013 and 2015 was performed. Patients with syndromes, immunodeficiency, cholesteatoma, chronic otitis media, cochlear implant in the affected ear, or incidental mastoid opacity were excluded. Results56 children age 6 months to 15 years old were treated for acute mastoiditis, including 29 hospitalizations and 27 outpatients. Patients managed as outpatient with daily intravenous ceftriaxone had a 93% cure rate. Eighteen hospitalized and one outpatient had complications of acute mastoiditis. Children with complications were more likely to be febrile (p = 0.045). Two patients failed outpatient therapy and were admitted; one for myringotomy and piperacillin-tazobactam treatment and one required a mastoidectomy. 4/27 children treated as outpatient underwent myringotomy and tube insertion, 2 underwent myringotomy and tube along with admission and 21 did not require tube insertion. The average total duration of intravenous antibiotic therapy was respectively 4.9 and 18.9 days in the outpatient and hospitalized group. The average duration of admission was 5.9 days. ConclusionOutpatient medical therapy of uncomplicated pediatric mastoiditis is safe, successful, and efficient. Benefits include efficient use of surgical beds, cost savings and patient and family convenience. Careful patient selection and close monitoring are keys for successful outcome.

Pediatric leukodystrophies: The role of the otolaryngologist

BackgroundLeukodystrophies consist of degenerative neurogenetic diseases often associated with comorbidities that extend beyond the neurological system. Despite their impacts on patients' quality of life and risks of complications, head and neck symptomology is poorly reported in the literature. The objective of this study was to identify and quantify the main head and neck complaints among a cohort of patients diagnosed with leukodystrophies and define the role of the otolaryngologist as part of a multidisciplinary team for treating these patients. MethodsDuring the First Canadian National Conference on Leukodystrophies held at the Montreal's Children Hospital, a cohort of 12 patients diagnosed with leukodystrophies were recruited and evaluated by a multidisciplinary team. An otolaryngology-focused assessment was done through history and physical examination, and included a screening questionnaire for 23 common otolaryngology issues. If families reported a history of sialorrhea, a validated questionnaire (Drool Quality of Life Assessment Questionnaire (DroolQoL)) was subsequently distributed. Results from the questionnaires were then compiled and analyzed. ResultsOf the 12 recruited patients, 83% (10/12) were known to an otolaryngologist. Drooling affected 67% (8/12) of patients although only 37.5% (3/8) of patients had undergone medical or surgical therapies for this issue. Four patients experienced at least one aspiration pneumonia. 58% (7/12) of the patients had dysphagia, of whom 43% (3/12) were fed exclusively via gastrostomy tube and 28% (2/7) required thickening of feeds. Two patients, despite suspicion of dysphagia and aspiration, had never undergone evaluation. As for otologic issues, it was noted that 25% (3/12) of patients had a history of pressure equalizing tubes (PETs) and one patient had a history of hearing loss. ConclusionHead and neck comorbidities affect children with leukodystrophies. Therefore, the otolaryngologist should be part of the multidisciplinary team, specifically for the management of dysphagia and sialorrhea.

Literacy promotion at the Montreal Children's Hospital.

The foundations for language and literacy are set in utero when babies hear the tone of their mother's voice (1). There is strong evidence of a positive relationship between early literacy experiences and language and academic outcomes (2). Unfortunately, many parents do not know about the benefits of reading to and with young children, and many children enter school without the basic skills needed to learn to read and succeed. Physicians who have contact with young families are in a distinctive position to promote reading, though despite its evidence base, it has not yet become a universal intervention. A short description of the projects at the Montreal Children's Hospital is provided.

Frequent users of the pediatric emergency department.

Emergency department (ED) crowding is associated with increased morbidity and mortality. Its etiology is multifactorial, and frequent ED use (defined as more or equal to five visits per year) is a major contributor to high patient volumes. Our primary objective is to characterize the frequent user population. Our secondary objective is to examine risk factors for frequent emergency use. We conducted a retrospective cohort study of pediatric emergency department (PED) visits at the Montreal Children's Hospital using the Système Informatique Urgence (SIURGE), electronic medical record database. We analysed the relation between patient's characteristics and the number of PED visits over a 1-year period following the index visit. Patients totalling 52,088 accounted for 94,155 visits. Of those, 2,474 (4.7%) patients had five and more recurrent visits and accounted for 16.6% (15,612 visits) of the total PED visits. Lower level of acuity at index visit (odds ratio [OR] 0.85) was associated with a lower number of recurrent visits. Lower socioeconomic status (social deprivation index OR 1.09, material deprivation index OR 1.08) was associated with a higher number of recurrent visits. Asthma (OR 1.57); infectious ear, nose, and sinus disorders (OR 1.33); and other respiratory disorders (OR 1.56) were independently associated with a higher incidence of a recurrent visit within the year following the first visit. Our study is the first Canadian study to assess risk factors of frequent pediatric emergency use. The identified risk factors and diagnoses highlight the need for future evidence-based, targeted innovative research evaluating strategies to minimize ED crowding, to improve health outcomes and to improve patient satisfaction.

Longitudinal Cohort Study of Regenerative Endodontic Treatment for Immature Necrotic Permanent Teeth

IntroductionThe treatment of immature necrotic permanent teeth presents several clinical challenges in endodontics. Regenerative endodontic procedures (REPs) permit root development, increased canal wall thickness, and apical closure. This longitudinal cohort study aimed to evaluate the long-term clinical and radiographic outcomes of REPs of immature necrotic permanent teeth over a 30-month period. MethodsThis study was performed at the Division of Dentistry of the Montreal Children's Hospital, Montreal, Quebec, Canada. Twenty-eight immature necrotic permanent teeth from 22 patients were included in this study. All teeth were treated with a standardized REP protocol. Patients had follow-up appointments at 1, 2, 3, 6, 12, 18, 24, and 30 months. At each appointment, signs and symptoms were evaluated. Radiographic evaluation was also performed by a calibrated endodontist in order to analyze different parameters. ResultsOur results show a high survival rate (96.4%), clinical success (92.8%), and resolution of apical pathology (100%). Significant increases in the average root length (8.1%, P < .0001) and root thickness area (11.6%, P = .03) were observed after 30 months. In the study period, a significant decrease in the apical diameter was also noted, with 30.8% of the cases showing complete apical closure. Teeth with more immature stages of root development had a higher percentage of change in root thickness, length, and apical diameter; however, these results were not statistically significant. ConclusionsTeeth treated with REPs presented resolution of symptoms. Although clinical meaningful change was not achieved in all cases, increased root thickness, root length, and apical closure were observed at 30 months.

Burden of Healthcare-Associated Viral Respiratory Infections in Children's Hospitals.

Although healthcare-associated (HA) viral respiratory infections (VRIs) are common in pediatrics, no benchmark for comparison exists. We aimed to determine, compare, and assess determinants of unit-specific HA-VRI incidence rates in 2 children's hospitals. This study was a retrospective comparison of prospective cohorts. The Montreal Children's Hospital and the Cohen Children's Medical Center of New York perform prospective surveillance for HA-VRI using standardized definitions that require the presence of symptoms compatible with VRI and virus detection. Cases detected between April 1, 2010, and March 31, 2013, were identified using surveillance databases. Annual incidence rates were calculated, and a generalized estimating equation model was used to assess determinants of HA-VRI rates. The overall HA-VRI rate during the 3-year study period was significantly higher at Montreal Children's Hospital than that at Cohen Children's Medical Center of New York (1.91 vs 0.80 per 1000 patient-days, respectively; P < .0001). Overall, the HA-VRI incidence rate was lowest in the neonatal intensive care unit. Rates in the pediatric intensive care, oncology, and medical/surgical units were similar. The most common etiology of HA-VRI at both institutions was rhinovirus (49% of cases), followed by parainfluenza virus and respiratory syncytial virus. Hospitals with less than 50% single rooms had HA-VRI rates 1.33 (95% confidence interval, 1.29-1.37) times higher than hospitals with more than 50% single rooms for a given unit type. HA-VRI rates were substantial but different among 2 children's hospitals. Future studies should examine the effect of HA-VRI and evaluate best practices for preventing such infections.

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.

Previous aminoglycoside use and acute kidney injury risk in non-critically ill children.

Aminoglycosides (AG) are a group of bactericidal antibiotics with nephrotoxic effects that are commonly used in the treatment of hospitialized children. We have examined previous AG treatment as a risk factor for acute kidney injury (AKI) during current AG treatment. We performed a retrospective cohort study of children ranging in age from 1 month to 18 years who were treated with AG between October 2008 and April 2012 at Montreal's Children's Hospital. Children for whom no serum creatinine data (SCr) were available and those with baseline renal disease were excluded from the analysis. Main exposures were prior AG use (number and hours of prior treatments) and time since last AG treatment. The main outcome was AKI, defined on the basis of theKidney Disease: Improving Global Outcomes guidelines. Logistic regression was used to examine exposure-outcome associations. AG treatments episodes with Stage 1, 2, and 3 AKI, respectively, were associated with a median of 98 [interquartile range (IQR) 339], 231 (IQR 688), and 111 (IQR 505) h of prior AG treatment, respectively, versus non-AKI (median 0, IQR 54 h) (p < 0.0001). AKI episodes were associated with a mean (± standard deviation) of 1.5 ± 1.8 AG treatments in the previous 6months, versus 0.9 ± 1.6 AG treatments for non-AKI. The number of AG-treatment days during the preceding 6 months [adjusted odds ratio (adjOR) 1.04, 95% confidence interval (CI) 1.03-1.06; p < 0.001], younger age (adjOR 0.96, 95% CI 0.93-0.99; p = 0.009), admission to hematology-oncology department (adjOR 3.88, 95% CI 2.17-6.96; p < 0.001), and tobramycin use (adjOR 1.77, 95% CI 1.04-3.02; p = 0.04) were independently associated with AKI. Episodes with Stage 1 and 2 AKI were associated with fewer days since last treatment compared to non-AKI treatment (p < 0.02 and p < 0.005, respectively; Mann-Whitney test). Based on these results, priorAG treatment is a risk factor for AKI and should be considered when dosing and monitoring hospitalized children being treated with AG.

CLABSI Risk Factors in the NICU: Potential for Prevention: A PICNIC Study.

OBJECTIVE Central-line-associated bloodstream infections (CLABSI) are an important cause of morbidity and mortality in neonates. We aimed to determine whether intra-abdominal pathologies are an independent risk factor for CLABSI. METHODS We performed a retrospective matched case-control study of infants admitted to the neonatal intensive care units (NICUs) of the Montreal Children's Hospital (Montreal) and the Royal Alexandra Hospital, Edmonton, Canada. CLABSI cases that occurred between April 2009 and March 2014 were identified through local infection control databases. For each case, up to 3 controls were matched (National Healthcare Safety Network [NHSN] birth weight category, chronological age, and central venous catheter (CVC) dwell time at the time of CLABSI onset). Data were analyzed using conditional logistic regression. RESULTS We identified 120 cases and 293 controls. According to a matched univariate analysis, the following variables were significant risk factors for CLABSI: active intra-abdominal pathology (odds ratio [OR], 3.4; 95% confidence interval [CI], 1.8-6.4), abdominal surgery in the prior 7 days (OR, 3.5; 95% CI, 1.0-10.9); male sex (OR, 1.7; 95% CI, 1.1-2.6) and ≥3 heel punctures (OR, 4.0; 95% CI, 1.9-8.3). According to a multivariate matched analysis, intra-abdominal pathology (OR, 5.9; 95% CI, 2.5-14.1), and ≥3 heel punctures (OR, 5.4; 95% CI, 2.4-12.2) remained independent risk factors for CLABSI. CONCLUSION The presence of an active intra-abdominal pathology increased the risk of CLABSI by almost 6-fold. Similar to CLABSI in oncology patients, a subgroup of CLABSI with mucosal barrier injury should be considered for infants in the NICU with active intra-abdominal pathology. Infect Control Hosp Epidemiol 2016;1446-1452.

Assessing the Diagnostic Properties of a Graded Oral Provocation Challenge for the Diagnosis of Immediate and Nonimmediate Reactions to Amoxicillin in Children.

The diagnostic properties of a graded provocation challenge (PC) among children presenting with a rash in the course of amoxicillin treatment are currently unknown. To assess the accuracy and the negative predictive value of the PC in a cohort of children referred with suspected allergy to amoxicillin. A cohort study was conducted between March 1, 2012, and April 1, 2015, at the allergy clinic of the Montreal Children's Hospital, Montreal, Quebec, Canada. All children referred with suspected allergy to amoxicillin were approached. In addition, 346 eligible children were followed up to assess reactions to subsequent use of amoxicillin at the time of illness in cases with negative PC results. Data were collected on clinical characteristics, suspected antibiotic exposure, personal and first-degree relatives' comorbidities, and history of atopy and management of the reaction. Univariate and multivariate logistic regressions were compared to determine factors associated with immediate and nonimmediate reactions to the PC. All children had a graded PC. Reactions to the graded PC, the negative predictive value of the PC for nonimmediate reactions, and factors associated with immediate and nonimmediate reactions to the PC. A total of 818 children were assessed (median age, 1.7 years [interquartile range, 1.0-3.9 years]; 441 [53.9%] male). Among all participants, 770 (94.1%) tolerated the PC, 17 (2.1%) developed mild immediate reactions, and 31 (3.8%) developed nonimmediate reactions. The graded PC had a specificity of 100.0% (95% CI, 90.9%-100.0%), a negative predictive value of 89.1% (95% CI, 77.1%-95.5%), and a positive predictive value of 100.0% (95% CI, 86.3%-100.0%). Among all 346 participants eligible for annual follow-up, 250 (72.3%; 95% CI, 67.2%-76.8%) responded, 55 of whom received subsequent full treatment with amoxicillin; 49 of these 55 participants (89.1%) reported tolerance to subsequent full treatment with amoxicillin, while 6 (10.9%) developed nonimmediate cutaneous reactions. History of a reaction occurring within 5 minutes of exposure was associated with immediate reactions to the PC (adjusted odds ratio = 9.6; 95% CI, 1.5-64.0), while a rash that lasted longer than 7 days (adjusted odds ratio = 4.8; 95% CI, 1.4-16.4) and parental history of drug allergy (adjusted odds ratio = 3.0; 95% CI, 1.3-6.8) were associated with nonimmediate reactions to the PC. Graded PCs provide an accurate and safe confirmatory test for skin-related reactions to amoxicillin. Further studies are required to assess factors associated with the PC outcome groups.

'Fairness' and student selection: the case for mandatory air quotes.

Medical EducationVolume 50, Issue 6 p. 600-602 Commentary ‘Fairness’ and student selection: the case for mandatory air quotes Saleem Razack, Corresponding Author Saleem Razack Montreal, Quebec, CanadaCorrespondence: Saleem Razack, Montreal Children's Hospital, 1001 Boulevard Decarie, Montreal, Quebec, Canada, H4A 3J1. Tel 514 412 4400 ext 22919; E-mail: saleem.razack@mcgill.caSearch for more papers by this author Saleem Razack, Corresponding Author Saleem Razack Montreal, Quebec, CanadaCorrespondence: Saleem Razack, Montreal Children's Hospital, 1001 Boulevard Decarie, Montreal, Quebec, Canada, H4A 3J1. Tel 514 412 4400 ext 22919; E-mail: saleem.razack@mcgill.caSearch for more papers by this author First published: 11 May 2016 https://doi.org/10.1111/medu.12997Citations: 2Read the full textAboutPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL Share a linkShare onFacebookTwitterLinkedInRedditWechat No abstract is available for this article.Citing Literature Volume50, Issue6June 2016Pages 600-602 RelatedInformation