Canadian Tertiary Care Hospital Research Articles

Health Care Professionals' and Parents' Perspectives on the Use of AI for Pain Monitoring in the Neonatal Intensive Care Unit: Multisite Qualitative Study.

The use of artificial intelligence (AI) for pain assessment has the potential to address historical challenges in infant pain assessment. There is a dearth of information on the perceived benefits and barriers to the implementation of AI for neonatal pain monitoring in the neonatal intensive care unit (NICU) from the perspective of health care professionals (HCPs) and parents. This qualitative analysis provides novel data obtained from 2 large tertiary care hospitals in Canada and the United Kingdom. The aim of the study is to explore the perspectives of HCPs and parents regarding the use of AI for pain assessment in the NICU. In total, 20 HCPs and 20 parents of preterm infants were recruited and consented to participate from February 2020 to October 2022 in interviews asking about AI use for pain assessment in the NICU, potential benefits of the technology, and potential barriers to use. The 40 participants included 20 HCPs (17 women and 3 men) with an average of 19.4 (SD 10.69) years of experience in the NICU and 20 parents (mean age 34.4, SD 5.42 years) of preterm infants who were on average 43 (SD 30.34) days old. Six themes from the perspective of HCPs were identified: regular use of technology in the NICU, concerns with regard to AI integration, the potential to improve patient care, requirements for implementation, AI as a tool for pain assessment, and ethical considerations. Seven parent themes included the potential for improved care, increased parental distress, support for parents regarding AI, the impact on parent engagement, the importance of human care, requirements for integration, and the desire for choice in its use. A consistent theme was the importance of AI as a tool to inform clinical decision-making and not replace it. HCPs and parents expressed generally positive sentiments about the potential use of AI for pain assessment in the NICU, with HCPs highlighting important ethical considerations. This study identifies critical methodological and ethical perspectives from key stakeholders that should be noted by any team considering the creation and implementation of AI for pain monitoring in the NICU.

Association of Epigenetic Age and Outcome in Critically Ill Patients.

DNA methylation can be used to determine an individual's biological age, as opposed to chronological age, an indicator of underlying health status. This study aimed to assess epigenetic age in critically ill patients with and without sepsis to determine if higher epigenetic age is associated with admission diagnosis or mortality. Secondary analysis of whole blood DNA methylation data generated from a nested case-control study of critically ill septic and nonseptic patients. Four tertiary care hospitals in Canada. None. Critically ill patients with and without sepsis. Epigenetic age was derived from DNA methylation data using the Hannum and PhenoAge algorithms and deviation from the patient's chronological age in years was determined. Of the 66 patients with sepsis, 34 were male (51.5%), the mean age was 65.03 years and 25 patients (37.8%) died before discharge. Of the 68 nonseptic patients, 47 were male (69.1%), the mean age was 64.92 years and 25 (36.7%) died before discharge. Epigenetic age calculated using the PhenoAge algorithm showed a significant age acceleration of 4.97 years in septic patients (p = 0.045), but no significant acceleration in nonseptic patients. Epigenetic age calculated using the Hannum algorithm showed no significant acceleration in the septic or nonseptic patients. Similarly, in the combined septic and nonseptic cohorts, nonsurvivors showed an epigenetic age acceleration of 7.62 years (p = 0.004) using the PhenoAge algorithm while survivors showed no significant age acceleration. Survivor status was not associated with age acceleration using the Hannum algorithm. In critically ill patients, epigenetic age acceleration, as calculated by the PhenoAge algorithm, was associated with sepsis diagnosis and mortality.

The changing epidemiology of Clostridioides difficile infection and the NAP1/027 strain in two Québec hospitals: a 17-year time-series study.

To describe the epidemiology of healthcare-associated Clostridioides difficile infection (HA-CDI) in two Québec hospitals in Canada following the 2003 epidemic and to evaluate the impact of antibiotic stewardship on the incidence of HA-CDI and the NAP1/027 strain. Time-series analysis. Two Canadian tertiary care hospitals based in Montréal, Québec. Patients with a positive assay for toxigenic C. difficile were identified through infection control surveillance. All cases of HA-CDI, defined as symptoms occurring after 72 hours of hospital admission or within 4 weeks of hospitalization, were included. The incidence of HA-CDI and antibiotic utilization from 2003 to 2020 were analyzed with available C. difficile isolates. The impact of antibiotic utilization on HA-CDI incidence was estimated by a dynamic regression time-series model. Antibiotic utilization and the proportion of NAP1/027 strains were compared biannually for available isolates from 2010 to 2020. The incidence of HA-CDI decreased between 2003 and 2020 at both hospitals from 26.5 cases per 10,000 patient-days in 2003 to 4.9 cases per 10,000 patient-days in 2020 respectively. Over the study period, there were an increase in the utilization of third-generation cephalosporins and a decrease in usage of fluoroquinolones and clindamycin. A decrease in fluoroquinolone utilization was associated with a significant decrease in HA-CDI incidence as well as decrease in the NAP1/027 strain by approximately 80% in both hospitals. Decreased utilization of fluoroquinolones in two Québec hospitals was associated with a decrease in the incidence of HA-CDI and a genotype shift from NAP1/027 to non-NAP1/027 strains.

Social Determinants of Health in Pediatric Ophthalmology Patients: Availability of Data in the Electronic Health Record and Association With Clinic Attendance.

To characterize the availability of social determinants of health data in the electronic health record of pediatric ophthalmology patients and to examine the association of social determinants of health with attendance at scheduled operating room and clinic visits. This was a retrospective cohort study of pediatric ophthalmology patients seen at The Hospital for Sick Children between June 1, 2018, and May 23, 2022. Data were collected on demographics, diagnosis, and management-plan. The χ2 tests and multivariable regression were used to examine associations between social determinants of health and attendance at scheduled operating room and clinic visits. The cohort consisted of 26,102 study subjects with 31,288 unique eye-related diagnoses representing 57 unique ICD-10 codes. Availability of data in the electronic health record ranged from 100% for sex, age and postal code to 0.1% for ethnic group. Female sex (P = 0.004) and urbanicity (P = 0.05) were associated with higher operating room visit cancellations. Female sex (P = 0.002), age group 0-13 (P ≤ 0.001), low-medium neighborhood income quintile (P ≤ 0.001), residence of Northern Ontario (P ≤ 0.001), and urbanicity (P ≤ 0.001) were associated with higher clinic visit cancellations and no-shows. At a major tertiary-care hospital in Canada, key social determinant data such as ethnicity are not consistently available in the electronic health record of pediatric ophthalmology patients. Female sex, younger age, and living in a rural area or neighborhood with low-medium income quintile may be predictors of missed visits and require further study. This study highlights a need for improved documentation of social determinants of health variables in electronic health records.

Incidence and risk factors for recurrent Clostridioides difficile infection in pediatric at-risk groups in selected Pediatric Investigators Collaborative Network on Infections in Canada (PICNIC) hospitals.

Incidence and risk factors for recurrent Clostridioides difficile infection (rCDI) are well established in adults, though data are lacking in pediatrics. We aimed to determine incidence of and risk factors for rCDI in pediatrics. This retrospective cohort study of pediatric patients was conducted at 3 tertiary-care hospitals in Canada with laboratory-confirmed CDI between April 1, 2012, and March 31, 2017. rCDI was defined as an episode of CDI occurring 8 weeks or less from diagnostic test date of the primary episode. We used logistic regression to determine and quantify risk factors significantly associated with rCDI. In total, 286 patients were included in this study. The incidence proportion for rCDI was 12.9%. Among hospitalized patients, the incidence rate was estimated at 2.6 cases of rCDI per 1,000 hospital days at risk (95% confidence interval [CI], 1.7-3.9). Immunocompromised patients had higher incidence of rCDI (17.5%; P = .03) and higher odds of developing rCDI independently of antibiotic treatment given for the primary episode (odds ratio [OR], 2.31; 95% CI, 1.12-5.09). Treatment with vancomycin monotherapy did not show statistically significant protection from rCDI, independently of immunocompromised status (OR, 0.33; 95% CI, 0.05-1.15]). The identification of increased risk of rCDI in immunocompromised pediatric patients warrants further research into alternative therapies, prophylaxis, and prevention strategies to prevent recurrent disease burden within these groups. Treatment of the initial episode with vancomycin did not show statistically significant protection from rCDI.

Social Vulnerability and Frailty in Hospitalized Older Adults.

Social vulnerability is the accumulation of disadvantageous social circumstances resulting in susceptibility to adverse health outcomes. Associated with increased mortality, cognitive decline, and disability, social vulnerability has primarily been studied in large population databases rather than frail hospitalized individuals. We examined how social vulnerability contributes to hospital outcomes and use of hospital resources for older adults presenting to the Emergency Department. We analyzed patients 65 years of age or older admitted through the Emergency Department and consulted to internal medicine or geriatrics at a Canadian tertiary care hospital from July 2009 to September 2020. A 20-item social vulnerability index (SVI) and a 57-item frailty index (FI) were calculated, using a deficit accumulation approach. Outcomes were length of stay (LOS), extended hospital LOS designation, alternative level of care (ALC) designation, in-hospital mortality, and discharge to long-term care (LTC). In 1,146 patients (mean age 80.5±8.3, 54.0% female), mean SVI was 0.40±0.16 and FI was 0.44±0.14. The SVI scores were not associated with admission to hospital. Amongst those admitted, for every 0.1 unit increase in SVI, LOS increased by 1.15 days (p<.001) after adjusting for age, sex and FI. SVI was associated with staying over the expected LOS (aOR: 1.19, 1.05-1.34, p=.009) and ALC status (aOR 1.39, 1.12-1.74, p<.004). SVI was not associated with in-hospital mortality, but was associated with incident discharge to LTC (aOR 1.03, 1.02-1.04, p<.001). Independent of frailty, being socially vulnerable was associated with increased LOS, designation as ALC, and being discharged to LTC from hospital. Consideration of social vulnerability's influence on prolonged hospitalization and long-term care needs has implications for screening and hospital resources.

Do older adults respond to cognitive behavioral therapy aswell as younger adults? An analysis of a large, multi-diagnostic, real-world sample.

Older adults (OA; ≥55years of age) are underrepresented in patients receiving cognitive-behavioral therapy (CBT). This study evaluates mental health outcomes for OA compared to younger adults (YA; <55years of age) receiving CBT. This is a pre-post study comparing the effectiveness of CBT for OA (n=99) and YA (n=601) in a CBT service located in a university-affiliated tertiary care hospital in Canada. Data was collected between 2001 and 2021. Participants received a mean of 18.5 sessions (SD 10) of standard, evidence-based CBT with treatment integrity checks. The main outcome was clinically significant change, as measured by the Reliable Change Index (RCI). Secondary outcomes were change in the Global Severity Index (GSI-SCL) of the Symptoms Checklist-90 (Revised), and Clinical Global Improvement scores (CGI). The RCI allowed a comparison of treatment efficacy across diagnoses. Both groups experienced similar improvement on the RCI (2.92 [±3.64] vs. 3.15 [±4.86], p=0.65). Furthermore, 39% of OA and 42% of YA no longer met criteria for their diagnoses. Groups did not differ with respect to changes in the GSI-SCL. The CGI severity comparison suggested that OA had milder illness. In all outcomes (RCI, CGI and GSI-SCL), participants improved over time. This real-world study analyzed a large sample of OA and YA undergoing CBT for various mental health conditions. Both groups were found to benefit equally.

A novel Canadian multidisciplinary acute care pathway for people hospitalised with a diabetic foot ulcer.

This manuscript describes the implementation and initial evaluation of a novel Canadian acute care pathway for people with a diabetic foot ulcer (DFU). A multidisciplinary team developed and implemented an acute care pathway for patients with a DFU who presented to the emergency department (ED) and required hospitalisation at a tertiary care hospital in Canada. Processes of care, length of stay (LOS), and hospitalisation costs were considered through retrospective cohort study of all DFU hospitalizations from pathway launch in December 2018 to December 2020. There were 82 DFU-related hospital admissions through the ED of which 55 required invasive intervention: 28 (34.1%) minor amputations, 16 (19.5%) abscess drainage and debridement, 6 (7.3%) lower extremity revascularisations, 5 (6.1%) major amputations. Mean hospital LOS was 8.8 ± 4.9 days. Mean hospitalisation cost was $20 569 (±14 143): $25 901 (±15 965) when surgical intervention was required and $9279 (±7106) when it was not. LOS and hospitalisation costs compared favourably to historical data. An acute care DFU pathway can support the efficient evaluation and management of patients hospitalised with a DFU. A dedicated multidisciplinary DFU care team is a valuable resource for hospitals in Canada.

Economic Impact of a Multidisciplinary Neurofibromatosis Clinic in a Canadian Tertiary Care Hospital (P8-13.001)

<h3>Objective:</h3> The objective of this research protocol is to measure the economic impact of implementing a multidisciplinary neurofibromatosis clinic in a Canadian tertiary care hospital. <h3>Background:</h3> Neurofibromatosis type 1 (NF1) is associated with a wide range of complications, such as psychological and physical pain due to neurofibromas and other tumors, increased risk of malignancy, neuropsychiatric comorbidities, unemployment, impaired quality of life, and reduced life expectancy. Consequently, NF1 patients require close monitoring from a number of specialists including neuro-oncologists, neurosurgeons, geneticists, and endocrinologists. Multidisciplinary clinics provide numerous advantages, such as increased access to care and reductions in no-show rates, and have been proven cost-effective in multiple clinical contexts. However, there have been no studies on the economic impact of multidisciplinary neurofibromatosis clinics. <h3>Design/Methods:</h3> We will perform a cost-effectiveness analysis of the Centre Hospitaliser de l’Université de Montréal (CHUM) multidisciplinary neurofibromatosis clinic, Quebec, Canada during a five-year period since its implementation in 2021. We will determine the cost of illness linked with NF1 in our province using a bottom-up cost estimation approach. We will then estimate the clinic-associated costs using administrative databases. Patients visiting the clinic will periodically answer a battery of questionnaires measuring the impact of their disease on quality of life, which will allow us to determine the quality-adjusted life-years (QALYs) gained from the intervention. We will determine the economic benefit of our clinic by combining total costs and QALY gains and comparing them to the estimated cost of illness. We will perform a sensitivity analysis to assess the validity of our results. <h3>Results:</h3> Not applicable <h3>Conclusions:</h3> This is the first study protocol assessing the economic impact of multidisciplinary medical care for NF1 patients. We hypothesize that this intervention is cost-effective and will positively impact the overall wellbeing of the NF1 population in our region. <b>Disclosure:</b> Dr. Rousseau has nothing to disclose. Dr. Lapointe has received personal compensation in the range of $500-$4,999 for serving on a Scientific Advisory or Data Safety Monitoring board for Alexion.

Effect of Ward-Based High-Flow Nasal Cannula (HFNC) Oxygen Therapy on Critical Care Utilization During the COVID-19 Pandemic: A Retrospective Cohort Analysis.

Hospitals expanded critical care capacity during the COVID-19 pandemic by treating COVID-19 patients with high-flow nasal cannula oxygen therapy (HFNC) in non-traditional settings, including general internal medicine (GIM) wards. The impact of this practice on intensive care unit (ICU) capacity is unknown. To describe how our hospital operationalized the use of HFNC on GIM wards, assess its impact on ICU capacity, and examine the characteristics and outcomes of treated patients. Retrospective cohort study of all patients treated with HFNC on GIM wards at a Canadian tertiary care hospital. All patients admitted with COVID-19 and treated with HFNC on GIM wards from December 28, 2020, to June 13, 2021, were included. We combined administrative data on critical care occupancy daily with chart-abstracted data for included patients to establish the total number of patients receiving ICU-level care at our hospital per day. We also collected data on demographics, medical comorbidities, illness severity, COVID-19 treatments, HFNC care processes, and patient outcomes. We treated 124 patients with HFNC on the GIM wards (median age 66 years; 48% female). Patients were treated with HFNC for a median of 5 days (IQR 3 to 8); collectively, they received HFNC for a total of 740 hospital days, 71% of which were on GIM wards. At peak ICU capacity strain (144%), delivering HFNC on GIM wards added 20% to overall ICU capacity by managing up to 14 patients per day. Patients required a median maximal fraction of inspired oxygen of 80% (IQR 60 to 95). There were 18 deaths (15%) and 85 patients (69%) required critical care admission; of those, 40 (47%) required mechanical ventilation. With appropriate training and resources, treatment of COVID-19 patients with HFNC on GIM wards appears to be a feasible strategy to increase critical care capacity.

Exploring the value of three-dimensional printing and virtualization in paediatric healthcare: A multi-case quality improvement study.

Three-dimensional printing is being utilized in clinical medicine to support activities including surgical planning, education, and medical device fabrication. To better understand the impacts of this technology, a survey was implemented with radiologists, specialist physicians, and surgeons at a tertiary care hospital in Canada, examining multidimensional value and considerations for uptake. To examine how three-dimensional printing can be integrated into the paediatric context and highlight areas of impact and value to the healthcare system using Kirkpatrick's Model. Secondarily, to explore the perspective of clinicians utilizing three-dimensional models and how they make decisions about whether or not to use the technology in patient care. A post-case survey. Descriptive statistics are provided for Likert-style questions, and a thematic analysis was conducted to identify common patterns in open-ended responses. In total, 37 respondents were surveyed across 19 clinical cases, providing their perspectives on model reaction, learning, behaviour, and results. We found surgeons and specialists to consider the models more beneficial than radiologists. Results further showed that the models were more helpful when used to assess the likelihood of success or failure of clinical management strategies, and for intraoperative orientation. We demonstrate that three-dimensional printed models could improve perioperative metrics, including a reduction in operating room time, but with a reciprocal effect on pre-procedural planning time. Clinicians who shared the models with patients and families thought it increased understanding of the disease and surgical procedure, and had no effect on their consultation time. Three-dimensional printing and virtualization were used in preoperative planning and for communication among the clinical care team, trainees, patients, and families. Three-dimensional models provide multidimensional value to clinical teams, patients, and the health system. Further investigation is warranted to assess value in other clinical areas, across disciplines, and from a health economics and outcomes perspective.

High Rates of Symptoms of Major Depressive Disorder and Panic Disorder in a Canadian Sample of Adolescents With Juvenile Idiopathic Arthritis.

We aimed to evaluate the rate of depressive and/or anxiety symptoms in adolescents with juvenile idiopathic arthritis (JIA) and to explore the association with demographic and disease activity measures. Depressive and anxiety symptoms were assessed in adolescents with JIA aged 12 to 18 years at a Canadian tertiary care hospital, using the Revised Child Anxiety and Depression Scale (RCADS). The RCADS includes 6 subscales: separation anxiety, social phobia, generalized anxiety, panic disorder, obsessive-compulsive, and major depressive disorder. Scores above clinical threshold on the RCADS subscales indicate that an individual's responses reflect symptoms similar to those diagnosed with the corresponding mental health disorder. Fisher exact test and Mann-Whitney U test were used to compare demographic and disease-related variables between participants who scored above and below clinical threshold on each of the subscales. There were 32/80 (40%) of participants who scored above clinical threshold on at least 1 subscale. Scores above clinical threshold were most frequent for major depressive disorder (23.8%) and panic disorder (22.5%) subscales. Social phobia and separation anxiety followed with 16.3% and 13.8%, respectively. Females were more likely to have scores above clinical threshold on the panic disorder subscale. Participants with higher self-reported disease activity were more likely to have scores above clinical threshold for all anxiety subscales except separation anxiety. We report high rates of symptoms of depression and anxiety (panic in particular) in adolescents with JIA. This highlights the ongoing need for mental health screening protocols and services. The relationships between concomitant mental health disorders, disease activity, and patient-reported outcomes requires further research.

Medical Assistance in Dying in Oncology Patients: A Canadian Academic Hospital’s Experience

Medical assistance in dying (MAID) was legislatively enacted in Canada in June 2016. Most studies of patients who received MAID grouped patients with cancer and non-cancer diagnoses. Our goal was to analyze the characteristics of oncology patients who received MAID in a Canadian tertiary care hospital. We conducted a retrospective review of all patients with cancer who received MAID between June 2016 and July 2020 at London Health Sciences Centre (LHSC). We describe patients' demographics, oncologic characteristics, symptoms, treatments, and palliative care involvement. Ninety-two oncology patients received MAID. The median age was 72. The leading cancer diagnoses among these patients were lung, colorectal, and pancreatic. At the time of MAID request, 68% of patients had metastatic disease. Most patients (90%) had ECOG performance status of 3 or 4 before receiving MAID. Ninety-nine percent of patients had distressing symptoms at time of MAID request, most commonly pain. One-third of patients with metastatic or recurrent cancer received early palliative care. The median time interval between the first MAID assessment and receipt of MAID was 7 days. Most oncology patients who received MAID at LHSC had poor performance status and almost all had distressing symptoms. The median time interval between first MAID assessment and receipt of MAID was shorter than expected. Only one-third of patients with metastatic or recurrent cancer received early palliative care. Improving access to early palliative care is a priority in patients with advanced cancer. We received research approval from Western University's Research Ethics Board (REB) with project ID number 115367, and from Lawson's Research Database Application (ReDA) with study ID number 9579.

Review of the utility of routine mortality reviews among deaths on General Internal Medicine wards in a Canadian tertiary care hospital

BackgroundHospital morbidity and mortality reviews are common quality assurance activities, intended to uncover latent or unrecognised systemic issues that contribute to preventable adverse events and patient harm. Mortality reviews may...

Getting Beyond Pros and Cons: Results of a Stakeholder Needs Assessment on Physician Assisted Dying in the Hospital Setting

This study assessed the attitudes and needs of physicians and health professional staff at a tertiary care hospital in Canada regarding the introduction of physician assisted dying (PAD) during 2015–16. This research aimed to develop an understanding of the wishes, concerns and hopes of stakeholders related to handling requests for PAD; to determine what supports/structures/resources health care professionals (HCP) require in order to ensure high quality and compassionate care for patients requesting PAD, and a supportive environment for all healthcare providers across the moral spectrum. This study constituted a mixed methods design with a qualitative descriptive approach for the study’s qualitative component. A total of 303 HCPs working in a tertiary care hospital completed an online survey and 64 HCPs working in hospital units with high mortality rates participated in 8 focus group discussions. Both focus group and survey data coalesced around several themes to support the implementation of PAD following the decriminalization of this practice: the importance of high quality care; honoring moral diversity; supporting values (such as autonomy, privacy, beneficence); and developing resources, including collaboration with palliative care, education, policies and a specialized team. This study provided the foundational evidence to support the development of the PAD program described in other papers in this collection, and can be a model for gathering evidence from stakeholders to inform the implementation of PAD in any healthcare organization.

A 2-Year Retrospective Case Series on Isolates of the Emerging Pathogen Actinotignum schaalii from a Canadian Tertiary Care Hospital.

(1) Background: Actinotignum schaalii is an emerging, opportunistic pathogen often linked with UTIs but can extend beyond the urogenital system. Data on the clinical significance of A. schaalii are still emerging. (2) Methods: A retrospective review of A. schaalii isolates in a Canadian tertiary care hospital was conducted. The clinical data of patients that grew A. schaalii from January 2020 to 2022 were documented. Demographics, site, management, and microbiological parameters surrounding culture and sensitivities were recorded. (3) Results: A total of 43 cases of A. schaalii were identified. Actinotignum schaalii was primarily involved in UTIs (n = 17), abscesses (n = 9), bacteremia (n = 6), septic arthritis (n = 5), and ulcers (n = 5). A. schaalii had a slight predilection for polymicrobial infections (51.1%, n = 22 out of 43), with Aerococcus urinae (n = 5) being the most common coisolate. Susceptibility testing was only performed in two cases that showed sensitivity to beta-lactam antibiotics and resistance to metronidazole and ciprofloxacin. Amoxicillin–clavulanate (n = 5) is the most frequently prescribed antibiotic. (4) Conclusions: The non-urogenic clinical significance of A. schaalii remains undervalued. The management of A. schaalii infection is multimodal, consisting predominantly of antimicrobials and surgical procedures specific to the etiology. Clinicians should request sensitivities for A. schaalii so that appropriate antimicrobial coverage can be provided.

Sex Differences in Determinants of Suicide Risk Preceding Psychiatric Admission: An Electronic Medical Record Study.

BackgroundIndividuals requiring inpatient psychiatric care represent a group at higher risk of progressing toward suicide attempt. Using electronic medical record (EMR) data collected from psychiatric inpatient admissions, the objective of this study was to identify sex differences in risk factors for suicide plans and/or attempts within the 30 days preceding hospital admission.MethodsResident Assessment Instrument for Mental Health (RAI-MH) intake data were obtained for patients admitted to a Canadian tertiary-care hospital deemed a “threat or danger to self” during a 10-year period (2008–2018). Data was extracted for individuals categorized into three groups: non-suicidal (N = 568), presence of suicide plan (N = 178), and presence of suspected suicide attempt (N = 124) in the 30 days prior to hospital admission. Multivariate logistic regression models were used to examine determinants of suicide risk.ResultsAcross all models, diagnosis of depression was the strongest predictor of suicide plan and/or attempt (OR = 5.54, 95% CI = 3.71–8.27, p < 0.001). Comparing clinical symptoms between suicidal and non-suicidal groups at the time of admission, the largest effect sizes were found for hopelessness (p < 0.001, η2 = 0.11), and guilt or shame (p < 0.001, η2 = 0.09). Female sex was identified as a significant factor for elevated suicidal risk (OR = 1.56, 95% CI = 1.01–2.21, p = 0.01), thus we stratified the regression model by sex to identify specific risk factors for suicide plan and/or attempt for males and females. Among males, having no confidant (OR = 2.13, 95% CI = 1.19–3.80, p = 0.01), presence of recent stressors (OR = 1.95, 95% CI = 1.16–3.29, p = 0.01), and participation in social activities (OR = 1.67, 95% CI = 1.02–2.71, p = 0.04) were important predictors, while among females, younger age (OR = 0.96, 95% CI = 0.94–0.97, p < 0.001) increased odds of suicide plan and/or attempt.ConclusionEMR-derived findings highlight different psychosocial and clinical determinants for males and females associated with suicide plan or attempt prior to psychiatric admission. Identifying precipitating factors that elevate imminent suicide risk may inform suicide prevention efforts for psychiatric inpatients.

Cerebrospinal Fluid Shunt Infections: A Multicenter Pediatric Study.

Infections complicate 5%-10% of cerebrospinal fluid (CSF) shunts. We aimed to describe the characteristics and contemporary pathogens of shunt infections in children in Canada and the United States. Descriptive case series at tertiary care hospitals in Canada (N = 8) and the United States (N = 3) of children up to 18 years of age with CSF shunt infections from July 1, 2013, through June 30, 2019. There were 154 children (43% female, median age 2.7 years, 50% premature) with ≥1 CSF shunt infections. Median time between shunt placement and infection was 54 days (interquartile range, 24 days-2.3 years). Common pathogens were coagulase-negative staphylococci (N = 42; 28%), methicillin-susceptible Staphylococcus aureus (N = 24; 16%), methicillin-resistant S. aureus (N = 9; 5.9%), Pseudomonas aeruginosa (N = 9; 5.9%) and other Gram-negative bacilli (N = 14; 9.0%). Significant differences between pathogens were observed, including timing of infection (P = 0.023) and CSF leukocyte count (P = 0.0019); however, differences were not sufficient to reliably predict the causative organism based on the timing of infection or discriminate P. aeruginosa from other pathogens based on clinical features. Empiric antibiotic regimens, which included vancomycin (71%), cefotaxime or ceftriaxone (29%) and antipseudomonal beta-lactams (33%), were discordant with the pathogen isolated in five cases. There was variability between sites in the distribution of pathogens and choice of empiric antibiotics. Nine children died; 4 (44%) deaths were attributed to shunt infection. Staphylococci remain the most common cause of CSF shunt infections, although antibiotic resistant Gram-negative bacilli occur and cannot be reliably predicted based on clinical characteristics.

Unexplained Significant Central Sleep Apnea in Infants: Clinical Presentation and Outcomes.

Unexplained significant central sleep apnea in term infants presents as central apneas with associated oxygen desaturations requiring respiratory support and monitoring for prolonged periods. However, there is a paucity of literature describing idiopathic central sleep apnea (ICSA) in term or near-term infants. Our aim was to describe the clinical manifestations, polysomnography data, interventions, and trajectory of ICSA in infants. This is a retrospective study of infants (gestational age ≥ 35weeks) who presented with significant central apneas and were subsequently diagnosed with ICSA following polysomnography and clinical investigations between January 2011 and April 2021 at a tertiary care hospital in Canada. Polysomnography data, clinical investigations, and treatments were documented. Eighteen infants (male, 78%; median gestational age 38weeks) with ICSA were included. Initial polysomnograms were completed at a median (interquartile range [IQR]) age of 1.2 (0.6-1.6) months (n = 18) and follow-up polysomnograms at 12.4 (10.6-14.0) months (n = 13). Compared to baseline diagnostic polysomnograms, at follow-up there was a significant reduction in the median (IQR) central apnea-hypopnea index (26.1 [18.2-52.9] versus 4.2[2.6-7.2] events/hour; p = 0.001), desaturation index (30.9 [12.2-57.4] versus 3.9[3.0-7.9] events/hour; p = 0.002), average transcutaneous carbon dioxide (41.9 [40.1-47.3 versus 39.4[37.5-42.7] mmHg; p = 0.025), and improved nadir oxygen saturation (79.8 [69.1-83.0] versus 85.5[83.2-87.8]%; p = 0.033), respectively. Prescribed treatments included supplemental oxygen (14/18, 78%), caffeine (5/18, 28%), and noninvasive ventilation (1/18, 6%). Infants with significant unexplained ICSA have a favorable clinical trajectory over time. Further research is needed to understand the etiology of this rare disorder.

Diagnosis of Endometriosis at Laparoscopy: A Validation Study Comparing Surgeon Visualization with Histologic Findings.

This study aimed to evaluate the validity of laparoscopic visualization for the diagnosis of endometriosis compared with histopathology. We conducted a retrospective chart review at a tertiary care hospital in Canada for the period of April 1, 2016 to March 31, 2017. Of 1069 women, 96 were selected for having undergone laparoscopic visualization and concurrent histopathological biopsy for suspected endometriosis. Standard measures of validity for diagnostic tests (sensitivity, specificity, positive predictive and negative predictive values, accuracy) were used. Mean age of the 96 women included was 40 ± 7.2 years, and median gravidity and parity were 1 (IQR 0-3) and 0 (IQR 0-2), respectively. Common symptoms were abdominal and pelvic pain (41.7%), menstrual bleeding concerns (34.4%), dysmenorrhea (29.2%), and infertility (8.3%). Approximately one-third of women had endometriomas (31.3%), while more than half had deep infiltrating endometriosis (59.4%). The diagnosis of endometriosis was made by surgeons at laparoscopic visualization in 82.3% of women and by histopathology in 74.0%. Using histopathology as the gold standard, sensitivity for laparoscopic visualization was 90.1% (95% CI 81.0-95.1), while specificity was 40.0% (95% CI 23.4-59.3). Positive and negative predictive values were 81.0% (95% CI 71.0-88.1) and 58.8% (95% CI 36.0-78.4), respectively; and the accuracy was 77.1% (95% CI 67.7-84.4). Although laparoscopic visualization had relatively high sensitivity and positive predictive value, its specificity and negative predictive value were relatively low. These findings support the use of laparoscopic visualization with histopathological analysis for accurate diagnosis of endometriosis.