Publications by authors named "Gregory Hansen"

52 Publications

The World Brain Death Project: The More You Say It Does Not Make It True.

J Clin Ethics 2021 ;32(2):97-108

Pediatric Intensive Care Unit, Royal Children's Hospital, 50 Flemington Rd., Parkville, Melbourne, 3052 Australia.

The World Brain Death Project clarified many aspects of the diagnosis of brain death/death by neurologic criteria. Clearer descriptions than previously published were presented concerning the etiology, prerequisites, minimum clinical criteria, apnea testing targets, and indications for ancillary testing. Nevertheless, there remained many epistemic and metaphysical assertions that were either false, ad hoc, or confused. Epistemically, the project was not successful in explaining away remaining brain functions, complex reflexes as "spinal," the risk and lack of utility of the apnea test, the ignored and often present confounders of central endocrine dysfunction and high-cervical-spinal-cord injury, the limitations of ancillary tests, or the cases of reversibility of some findings of brain death/death by neurologic criteria. Metaphysically, the World Brain Death Project variously suggested different concepts of death that were not supported with argument. Concepts offered included simply restating the criterion of brain death/death by neurologic criteria; personhood, without recognizing it is a higher-brain concept; and emergent functions of the organism as a whole, without specifying what these might be, if not biologic anti-entropic integration that actually remains after brain death/death by neurologic criteria. The World Brain Death Project only offered confused metaphysical discussion, and gave no reason why the state they described as brain death/death by neurologic criteria should be considered death itself. The main epistemic and metaphysical problems with brain death/death by neurologic criteria remain untouched by the World Brain Death Project.
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June 2021

Computed Tomography Practice Standards for Severe Pediatric Traumatic Brain Injury in the Emergency Department: a National Survey.

J Child Adolesc Trauma 2021 Jun 18;14(2):271-276. Epub 2020 Sep 18.

Division of Pediatric Critical Care, Jim Pattison Children's Hospital, Saskatoon, Saskatchewan Canada.

Acute medical management of traumatic brain injury (TBI) can be challenging outside of the resuscitation bay, specifically while obtaining a computed tomography (CT) scan of the brain. We sought out to determine the management practices of Canadian traumatologists for pediatric patients with severe TBI requiring CT in the emergency department (ED). In 2019, surveys were sent to trauma directors in hospitals across Canada to ascertain their clinical practices. Team members present in the CT scan included physicians (89%), registered nurses (100%), and respiratory therapists (38%). The average time to and from the CT scanner was one hour. Over half of respondents (56%) had experienced an adverse event in CT with variable access (11-56%) to necessary resuscitation equipment and medications. Significant hypotension (44%) was the most common adverse event experienced. With the exception of an end tidal CO monitoring (56%), heart rate, rhythm, respiratory rate, saturation, and blood pressure were always monitored during a CT scan. Head of bed elevation had an approximately equal distribution of flat (44%) versus elevated (56%). The practice variability of Canadian traumatologists may reflect a lack of evidence to guide patient management. Future research and knowledge translation efforts are needed to optimize patient care during neuroimaging.
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http://dx.doi.org/10.1007/s40653-020-00317-xDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8099959PMC
June 2021

Optic Nerve Sheath Diameter in Preterm Infants: Suggested Values.

Neonatology 2021 23;118(3):297-300. Epub 2021 Mar 23.

Division of Pediatric Critical Care, Jim Pattison Children's Hospital, Saskatoon, Saskatchewan, Canada,

Objective: Timely detection of elevated intracranial pressure (ICP) in highrisk preterm infants may be critical to avoid permanent neurologic sequelae. Size of optic nerve sheath diameter (ONSD) is highly correlated with changes in ICP. Normal ultrasonographic ONSD values for preterm infants have been published. This study sought to compare these data with MRI measured OSND and to propose suggested ultrasonographic ONSD values.

Methods: The ONSD in preterm MRIs were retrospectively measured and related to pre-existing ultrasonographic ONSD. Data were stratified for corrected gestational age. Simple linear regression between ONSD mean values and age was modeled for both eyes, and R2 was calculated. Suggested values for ultrasonographic ONSD were ascertained through linear regression and calculated prediction intervals.

Results: ONSD measurements demonstrated R2 values of 0.95 (right ONSD MRI), 0.95 (left ONSD MRI), 0.96 (right ONSD ultrasound), and 0.93 (left ONSD ultrasound). Suggested ONSD values were incremental with corrected gestational age.

Conclusion: ONSD measurements with MRI and ultrasound are similar. The proposed suggested ONSD values may be helpful in clinical situations where ICPs are suspected or known.
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http://dx.doi.org/10.1159/000513721DOI Listing
March 2021

Characterization of Ebola Virus Risk to Bedside Providers in an Intensive Care Environment.

Microorganisms 2021 Feb 26;9(3). Epub 2021 Feb 26.

Department of Paediatrics & Child Health, College of Medicine, Faculty of Health Sciences, University of Manitoba, Winnipeg, MB R3A 1S1, Canada.

Background: The 2014-2016 Ebola outbreak in West Africa recapitulated that nosocomial spread of Ebola virus could occur and that health care workers were at particular risk including notable cases in Europe and North America. These instances highlighted the need for centers to better prepare for potential Ebola virus cases; including understanding how the virus spreads and which interventions pose the greatest risk.

Methods: We created a fully equipped intensive care unit (ICU), within a Biosafety Level 4 (BSL4) laboratory, and infected multiple sedated non-human primates (NHPs) with Ebola virus. While providing bedside care, we sampled blood, urine, and gastric residuals; as well as buccal, ocular, nasal, rectal, and skin swabs, to assess the risks associated with routine care. We also assessed the physical environment at end-point.

Results: Although viral RNA was detectable in blood as early as three days post-infection, it was not detectable in the urine, gastric fluid, or swabs until late-stage disease. While droplet spread and fomite contamination were present on a few of the surfaces that were routinely touched while providing care in the ICU for the infected animal, these may have been abrogated through good routine hygiene practices.

Conclusions: Overall this study has helped further our understanding of which procedures may pose the highest risk to healthcare providers and provides temporal evidence of this over the clinical course of disease.
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http://dx.doi.org/10.3390/microorganisms9030498DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7996731PMC
February 2021

Canada's Decentralized "Human-Driven" Approach During the Early COVID-19 Pandemic.

JMIR Public Health Surveill 2020 12 23;6(4):e20343. Epub 2020 Dec 23.

Department of Pediatrics, College of Medicine, University of Saskatchewan, Saskatoon, SK, Canada.

A country's early response to a pandemic is critical for controlling the disease outbreak. During the COVID-19 pandemic, a number of southeast Asian countries adopted centralized, coordinated, rapid, and comprehensive approaches that involved smart technology (the "techno-driven" approach). In comparison, Canada's approach appeared to be decentralized, uncoordinated, and slow, and it focused on educating citizens and enhancing social and human capital (the "human-driven" approach). We propose that in future pandemics, early and coordinated "techno-driven" approaches should receive more careful consideration to curtail outbreaks; however, these approaches must be balanced with protecting individuals' freedoms.
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http://dx.doi.org/10.2196/20343DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7759506PMC
December 2020

Automated Device for Uncapping Multiple-Size Bioanalytical Sample Tubes Designed to Reduce Technician Strain and Increase Productivity.

SLAS Technol 2021 Jun 22;26(3):320-326. Epub 2020 Oct 22.

Department of Biomedical Engineering, University of Wisconsin-Madison, Madison, WI, USA.

Technicians in a commercial laboratory manually uncap up to 700 sample tubes daily in preparation for bioanalytical testing. Manually twisting off sample tube caps not only is a time-consuming task, but also poses increased risk for muscle fatigue and repetitive-motion injuries. An automated device capable of uncapping sample tubes at a rate faster than the current workflow would be valuable for minimizing strain on technicians' hands and saving time. Although several commercial sample tube-uncapping products exist, they are not always usable for a workload that uses a mix of tube sizes and specific workflow. A functioning uncapping device was developed that can semi-automatically uncap sample tubes with three different heights and diameters and was compatible with the workflow in a commercial laboratory setting. Under limited testing, the average success rate with uncapping each of the three sample tube sizes or a mix of them was 90% or more, more than three times faster than manual uncapping, and met standard acceptance criteria using mass spectrometry. Our device with its current performance is still a prototype, requiring further development. It showed promise for ergonomic benefit to the laboratory technicians, however, reducing the necessity to manually unscrew caps.
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http://dx.doi.org/10.1177/2472630320967622DOI Listing
June 2021

Perspectives of Pediatric Providers on Patients With Complex Chronic Conditions: A Mixed-Methods Sequential Explanatory Study.

Crit Care Nurse 2020 Oct;40(5):e10-e17

Tanya R. Holt is Director of the pediatric intensive care unit, Department of Pediatrics, University of Saskatchewan.

Background: Children with complex chronic conditions present unique challenges to the pediatric intensive care unit, including prolonged length of stay, complex medical regimens, and complicated family dynamics.

Objectives: To examine perspectives of pediatric intensive care unit health care providers regarding pediatric patients with complex chronic conditions, and to explore potential opportunities to improve these patients' care.

Methods: A prospective mixed-methods sequential explanatory study was conducted in a tertiary medical-surgical pediatric intensive care unit using surveys performed with REDCap (Research Electronic Data Capture) followed by semistructured interviews.

Results: The survey response rate was 70.6% (77 of 109). Perspectives of health care providers did not vary with duration of work experience. Ten semistructured interviews were conducted. Eight overarching themes emerged from the interviews: (1) the desire for increased formal education specific to pediatric complex chronic care patients; (2) designation of a primary intensivist; (3) modifying delivery of care to include a discrete location for care provision; (4) establishing daily, short-term, and long-term goals; (5) monitoring and documenting care milestones; (6) strengthening patient and family communications with the health care team; (7) optimizing discharge coordination and planning; and (8) integrating families into care responsibilities.

Conclusions: Pediatric intensive care unit health care providers' perspectives of pediatric patients with complex chronic conditions indicated opportunities to refine the care provided by establishing daily goals, coordinating discharge planning, and creating occasions for close communication between patients, families, and providers.
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http://dx.doi.org/10.4037/ccn2020710DOI Listing
October 2020

Photovoice as a Participatory Research Tool in Amyotrophic Lateral Sclerosis.

J Neuromuscul Dis 2021 ;8(1):91-99

Department of Medicine, Division of Neurology, University of Saskatchewan, Saskatoon, Saskatchewan, Canada.

Background: Photovoice is a qualitative research tool increasingly utilized in the healthcare field to understand the illness experience from the patient and caregiver perspective. This is the first study to evaluate photovoice in the context of amyotrophic lateral sclerosis (ALS).

Objective: A patient and caregiver centered research tool was utilized to gain a greater understanding of challenges faced when living with ALS.

Methods: Eight patients and three corresponding caregivers participating by taking photographs, writing descriptive text, and participating in individual and group interviews. Inductive thematic analysis was employed to uncover recurring themes.

Results: Five main themes were identified; 1) facing the diagnosis, 2) loss of function, 3) isolation, 4) health system challenges, and 5) hope. Despite the devasting impact of ALS, the majority of participants reported a surprising amount of positivity in the face of receiving this difficult diagnosis, and demonstrated incredible creativity and adaptability to meet the ensuing loss of function. However, patients and caregivers discussed feelings of isolation and health care system challenges. The importance of hope was a strong and recurring theme.

Conclusions: The photovoice research tool demonstrates the profound resilience of these participants, and challenges the medical community to find ways of fostering positivity and hope throughout the ALS disease course. Further clinic and community resources, education, and supports are needed to combat the sense of isolation and health care system challenges experienced by patients and their caregivers.
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http://dx.doi.org/10.3233/JND-200537DOI Listing
January 2021

Serial Clinical Scoring to Assess Transported Pediatric Patients.

Pediatr Emerg Care 2020 Jun 3. Epub 2020 Jun 3.

From the Pediatric Intensive Care Unit, Division of Pediatric Critical Care, Jim Pattison Children's Hospital.

Objectives: The objective of this study was to evaluate serial Transport Risk Assessment in Pediatrics (TRAP) scoring during pediatric critical care transport as a potential measure for specialized pediatric transport teams (PTTs).

Methods: This was a retrospective study with a provincial PTT from a tertiary hospital pediatric intensive care unit. All acutely ill children who were transported by the PTT between 2018 and 2019 were included in the study. The TRAP scores were measured at time of transport team arrival (TRAP1), time at arrival to tertiary center (TRAP2), and 4 hours postarrival to tertiary center (TRAP3).

Results: A total of 300 transports were included. Patients' mean age was 54 months, with lower respiratory tract infection (40.7%) as the most common diagnosis. There were significant differences between TRAP1-TRAP2 (P < 0.01) and TRAP1-TRAP3 (P < 0.01), but not between TRAP2-TRAP3 (P = 0.67). The most significant improvements of ΔTRAP1-TRAP2 scores were seen in septic shock (mean, 2.0; SD, 1.7).

Conclusions: The TRAP scores improved following the PTTs' arrival to acutely ill children, particularly with sepsis. Serial TRAP scoring may present a system for evaluation of team performance and/or characterize disease states that are positively impacted by PTTs. Future prospective evaluation is needed to validate TRAP for this purpose.
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http://dx.doi.org/10.1097/PEC.0000000000002132DOI Listing
June 2020

Noninvasive ventilation for pediatric interfacility transports: a retrospective study.

World J Pediatr 2020 Aug 13;16(4):422-425. Epub 2020 May 13.

Division of Pediatric Critical Care, Jim Pattison Children's Hospital, 103 Hospital Drive, Saskatoon, SK, S7N 0W8, Canada.

Background: To characterize pediatric patients supported with continuous positive airway pressure and bilevel positive airway pressure (CPAP/BiPAP) or high-flow nasal cannula (HFNC) during interfacility transport (IFT).

Methods: A retrospective study with a provincial pediatric transport team from a tertiary hospital pediatric intensive care unit. Pediatric patients aged 28 days to < 17 years, who required IFT between January 2017 and December 2018, were identified through a transport registry and were included in the study.

Results: A total of 118 (26.7%) patients received CPAP/BIPAP or HFNC support for IFT. The most common respiratory diagnosis was bronchiolitis (46%). These patients were placed on respiratory support, 31.4 minutes after the transport team's arrival. None required intubation during their IFT, despite mean transport times of 163 minutes.

Conclusions: This study may provide important information for programs with large catchment areas, in which large distances and transport times should not be barriers to NIV implementation.
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http://dx.doi.org/10.1007/s12519-020-00363-3DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7222886PMC
August 2020

Rare cause of emergency in the first week of life: congenital hepatoblastoma (case report).

Oxf Med Case Reports 2020 Feb 24;2020(2):omaa002. Epub 2020 Feb 24.

Faculty of Pediatrics, University of Saskatchewan, Saskatoon, SK S7N 5E5, Canada.

During the first week of life, a sudden deterioration in a newborn commonly includes investigations to rule out infections, lung pathologies, cardiac lesions, neurological insults, metabolic disorders or gastrointestinal emergencies. It is unusual, however, to consider malignancy as the primary causative factor. In this case report, we describe a rare and unusual presentation of congenital hepatoblastoma, its complications and management in a neonate with multi-organ dysfunction. A term infant presented with sudden deterioration, hemodynamic instability and an acute abdomen on his 4th day of life. Surgical exploration revealed a ruptured neoplasm that pathology diagnosed as a congenital hepatoblastoma. After the patient was stabilized, chemotherapy was initiated. At present, the patient is 8 months old and under continuous follow-up of oncology service. This case highlights the importance of considering rare diagnoses including congenital malignancy when investigating and managing a sick newborn with multi-organ dysfunction.
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http://dx.doi.org/10.1093/omcr/omaa002DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7037083PMC
February 2020

Rural Residence and Diagnostic Delay for Amyotrophic Lateral Sclerosis in Saskatchewan.

Can J Neurol Sci 2020 07 26;47(4):538-542. Epub 2020 Feb 26.

Division of Neurology, Department of Medicine, University of Saskatchewan, Saskatoon, SK, Canada.

Background: Diagnostic delay in amyotrophic lateral sclerosis (ALS) is common. In a recent Canadian study evaluating provincial differences in care, Saskatchewan had the longest delay at 27 months. Since Saskatchewan has a large rural population, this study sought to determine whether geographically determined access to a neurologist at tertiary centers could be contributing to this lengthy delay.

Methods: A retrospective chart review of 171 patients seen in the ALS clinic in Saskatoon, Saskatchewan was performed. Urban or rural location, distance from nearest tertiary center, and clinically relevant data were collected.

Results: There was no difference between urban and rural populations for delay in symptom onset to diagnosis. For rural patients, linear regression modeling did not uncover a significant relationship between distance from tertiary center and time to diagnosis. Additionally, there were no differences between urban and rural dwellers either for referral or utilization of feeding tube, noninvasive ventilation, riluzole, or communication devices. Contrary to the previous data showing a 27-month diagnostic delay in Saskatchewan, our study which included a larger provincial population found the mean diagnostic delay was 16.6 months.

Conclusions: This study did not uncover differences in diagnostic delay or ALS care between urban and rural dwellers. Further study is required to determine reproducibility of results.
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http://dx.doi.org/10.1017/cjn.2020.38DOI Listing
July 2020

Brain Death Criteria: Medical Dogma and Outliers.

Yale J Biol Med 2019 12 20;92(4):751-755. Epub 2019 Dec 20.

Division of Critical Care, Department of Pediatrics, University of Saskatchewan, Saskatoon, Saskatchewan, Canada.

The diagnosis of brain death (BD) is legally and medically accepted. Recently, several high-profile cases have led to discussions regarding the integrity of current criteria, and many physiologic problems have been identified to support the necessity for their reevaluation. These include a global variability of the criteria, the suggestion of a clinical "hierarchy," and the resultant approximation of BD. Further ambiguity has been exposed through case reports of reversible BD, and an inconsistent understanding from physicians who are viewed as experts in this domain. Meeting BD criteria clearly does not equate to a physiologic "death" of the brain, and a greater community perspective should be considered as the dialogue moves forward.
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http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6913809PMC
December 2019

Correction to: Impact of intensive care unit supportive care on the physiology of Ebola virus disease in a universally lethal non-human primate model.

Intensive Care Med Exp 2019 Dec 4;7(1):66. Epub 2019 Dec 4.

National Microbiology Laboratory, Public Health Agency of Canada, 1015 rue Arlington Street, Winnipeg, Manitoba, R3E 3R2, Canada.

Please note that four authors (Logan Banadyga, Alixandra Albietz, Brad Pickering, and Gary Wong) have been erroneously omitted from the author list in the published original article [1].
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http://dx.doi.org/10.1186/s40635-019-0283-9DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6892986PMC
December 2019

Impact of intensive care unit supportive care on the physiology of Ebola virus disease in a universally lethal non-human primate model.

Intensive Care Med Exp 2019 Sep 13;7(1):54. Epub 2019 Sep 13.

National Microbiology Laboratory, Public Health Agency of Canada, 1015 rue Arlington Street, Winnipeg, Manitoba, R3E 3R2, Canada.

Background: There are currently limited data for the use of specific antiviral therapies for the treatment of Ebola virus disease (EVD). While there is anecdotal evidence that supportive care may be effective, there is a paucity of direct experimental data to demonstrate a role for supportive care in EVD. We studied the impact of ICU-level supportive care interventions including fluid resuscitation, vasoactive medications, blood transfusion, hydrocortisone, and ventilator support on the pathophysiology of EVD in rhesus macaques infected with a universally lethal dose of Ebola virus strain Makona C07.

Methods: Four NHPs were infected with a universally lethal dose Ebola virus strain Makona, in accordance with the gold standard lethal Ebola NHP challenge model. Following infection, the following therapeutic interventions were employed: continuous bedside supportive care, ventilator support, judicious fluid resuscitation, vasoactive medications, blood transfusion, and hydrocortisone as needed to treat cardiovascular compromise. A range of physiological parameters were continuously monitored to gage any response to the interventions.

Results: All four NHPs developed EVD and demonstrated a similar clinical course. All animals reached a terminal endpoint, which occurred at an average time of 166.5 ± 14.8 h post-infection. Fluid administration may have temporarily blunted a rise in lactate, but the effect was short lived. Vasoactive medications resulted in short-lived improvements in mean arterial pressure. Blood transfusion and hydrocortisone did not appear to have a significant positive impact on the course of the disease.

Conclusions: The model employed for this study is reflective of an intramuscular infection in humans (e.g., needle stick) and is highly lethal to NHPs. Using this model, we found that the animals developed progressive severe organ dysfunction and profound shock preceding death. While the overall impact of supportive care on the observed pathophysiology was limited, we did observe some time-dependent positive responses. Since this model is highly lethal, it does not reflect the full spectrum of human EVD. Our findings support the need for continued development of animal models that replicate the spectrum of human disease as well as ongoing development of anti-Ebola therapies to complement supportive care.
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http://dx.doi.org/10.1186/s40635-019-0268-8DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6744539PMC
September 2019

Thoracic electrical impedance tomography to minimize right heart strain following cardiac arrest.

Ann Pediatr Cardiol 2019 Sep-Dec;12(3):315-317

Department of Pediatrics, Division of Pediatric Critical Care, College of Medicine, University of Saskatchewan, Saskatoon, Saskatchewan, Canada.

Titrating ventilator settings to minimize pulmonary arterial pressures and optimize both ventilation and oxygen delivery can be challenging following cardiac arrest. Erroneous ventilator adjustments can lead to unnecessary strain on the right ventricle that may be particularly vulnerable during the acute recovery. We report a child with fulminant myocarditis who was mechanically ventilated using thoracic electrical impedance tomography to optimize regional lung inflation and possibly curtail right ventricular afterload following cardiac arrest.
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http://dx.doi.org/10.4103/apc.APC_189_18DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6716314PMC
September 2019

Optic Nerve Sheath Diameter for Preterm Infants: A Pilot Study.

Neonatology 2019 19;116(1):1-5. Epub 2019 Mar 19.

Division of Pediatric Critical Care, Department of Pediatrics, College of Medicine, University of Saskatchewan, Saskatoon, Saskatchewan, Canada,

Objective: In preterm infants, early diagnosis and management of a raised intracranial pressure (ICP) may be important to improve neurodevelopmental outcomes. While invasive ICP monitoring is not recommended, ultrasonography of the optic nerve sheath diameter (ONSD) could provide a noninvasive alternative to evaluate ICP. The objective of this pilot study was to document ranges of ONSD in preterm infants.

Methods: This prospective cohort pilot evaluated preterm infants who were admitted to the neonatal intensive care unit without suspected raised ICP. Three images per eye were obtained from a 20-5 MHz linear array ultrasound transducer placed on the patient's superior eyelid. The OSND was measured 3 mm behind the globe. A second ultrasonographer duplicated half of the scans. Multiple linear regression analysis was conducted for both right and left ONSD with corrected gestational age, weight, and head circumference as predictors. Lin's concordance assessed interrater reliability.

Results: In 12 preterm infants 114 scans were performed on both eyes. The median age was 33 weeks (corrected gestational age) with a range of 29-36 weeks. Corrected gestational age was the strongest predictor for ONSD, and preliminary measurements at each gestational age were established. Interrater reliability demonstrated substantial agreement (Qc = 0.97).

Conclusion: In preterm infants, ONSD strongly correlates with corrected gestational age. These data should be validated with other imaging modalities before abnormal ranges can be considered.
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http://dx.doi.org/10.1159/000497163DOI Listing
May 2020

Pediatric early warning score and deteriorating ward patients on high-flow therapy.

Pediatr Int 2019 Mar 18;61(3):278-283. Epub 2019 Mar 18.

Division of Pediatric Critical Care, Department of Pediatrics, College of Medicine, University of Saskatchewan, Saskatoon, Saskatchewan, Canada.

Background: Delivery of non-invasive ventilation commonly occurs in the pediatric intensive care unit (PICU). With the advent of high-flow nasal cannula (HFNC), patients with respiratory distress may be rescued on the ward without a PICU admission. We evaluated our ward HFNC algorithm to determine its safety profile and independent predictors for non-responders, defined as requiring subsequent PICU admission.

Methods: A retrospective chart review of patients <17 years of age admitted with respiratory distress between 2016 and 2017 was carried out. Pediatric Early Warning System (PEWS) respiratory score was used to assess the clinical response of patients requiring HFNC. Variables associated with non-responders were evaluated, and their PICU admission was studied for escalation of care and criticality.

Results: Patients with comorbidities (P = 0.02) were more likely to require HFNC. Of the 18 patients initiated on HFNC, 44% (n = 8) remained on the ward. Non-responders (n = 10; 56%) had higher (2.7 vs 1.8; P = 0.03) and worsening (-0.1 vs 0.3; P = 0.05) PEWS respiratory scores 90 min after HFNC initiation. Eighty percent (n = 8) of non-responders required escalation to continuous positive airway pressure or bilevel positive airway pressure in the PICU. For both HFNC responders and non-responders, there were no requirements for intubation, evidence of air leak or difference in days of respiratory support.

Conclusions: High and worsening PEWS scores 90 min after HFNC initiation may indicate non-response when coupled with a standardized ward HFNC algorithm for respiratory distress. Further improvements may be seen with an earlier initiation of HFNC in the emergency department and more aggressive flow escalation on the ward.
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http://dx.doi.org/10.1111/ped.13787DOI Listing
March 2019

Pulmonary Thromboses in Pediatric Acute Respiratory Distress Syndrome.

Respir Care 2019 Feb 24;64(2):209-216. Epub 2018 Dec 24.

Division of Pediatric Critical Care, Department of Pediatrics, College of Medicine, University of Saskatchewan, Saskatoon, Saskatchewan, Canada.

Pediatric ARDS continues to be a management challenge in the ICU with prolonged hospitalizations and high mortality. Thromboembolic pulmonary embolism and in situ pulmonary artery thrombosis might represent underappreciated thrombotic processes for a subset of these patients. Although well described in the adult literature, descriptions of pulmonary thromboses with pediatric ARDS are limited to case reports. However, many risk factors for pulmonary thromboses are present in children with ARDS (eg, coagulopathy, endothelial injury, central venous catheters, concomitant inflammatory diseases), suggesting a much higher incidence is plausible. Based on an interpretation of animal, pediatric, and adult data, we propose a diagnostic algorithm to facilitate a timely and accurate diagnosis. Observing an alveolar dead space fraction ≥ 0.25, or either a 50% increase in physiologic dead space/tidal volume or a central venous saturation ≤ 60% over 24 h, triggers the algorithm. Together with targeted heparin treatment and right ventricular afterload reduction, clinical outcomes might improve if this particular patient subgroup can be identified early. While anticoagulation is recommended in adults with confirmed pulmonary embolism and low early mortality risk, data for children are limited.
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http://dx.doi.org/10.4187/respcare.06106DOI Listing
February 2019

Patient perspectives on transitioning to amyotrophic lateral sclerosis multidisciplinary clinics.

J Multidiscip Healthc 2018 1;11:519-524. Epub 2018 Oct 1.

Department of Pediatrics, Division of Critical Care, University of Saskatchewan, Saskatoon, SK, Canada.

Purpose: Multidisciplinary clinics (MDC) have become the standard of care for management of amyotrophic lateral sclerosis (ALS). No studies however, have captured patients' perspectives during a transition to ALS MDCs. Recently, an ALS MDC emerged from a single-physician clinic in Saskatoon, Canada, providing patients with a unique exposure to two different models of care.

Patients And Methods: Fifteen patients with ALS participated in semi-structured interviews that were digitally recorded and transcribed. Two independent researchers performed an inductive thematic analysis. Information was coded based on emerging and a priori themes. An iterative process followed involving discussion and reexamination of the themes until consensus was reached.

Results: All patients cited the convenience of integrated care as an advantage. Other advantages included clinical expertise and advocacy potential. Travel and reduced mobility were the most commonly discussed barriers/disadvantages of MDC attendance. The impact of geography and weather appeared to augment both the appreciation of an integrated approach and the impediment of travel, compared to the existing literature. The need for individualized care was demonstrated by the conflicting viewpoints obtained from participants. Most patients felt additional practitioners and supports for both patients and caregivers were required.

Conclusion: ALS patients transitioned to MDCs reported many of the advantages and disadvantages reported elsewhere. A novel perspective of a MDC's advocacy potential was recognized, and the need for an innovative approach to meet demands for individualized care was highlighted.
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http://dx.doi.org/10.2147/JMDH.S177563DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6171753PMC
October 2018

Survey of Nutrition Practice in Patients with Severe Sepsis among Canadian Registered Dietitians.

Can J Diet Pract Res 2019 03 3;80(1):8-13. Epub 2018 Oct 3.

c Division of Pediatric Intensive Care, University of Saskatchewan, Saskatoon, SK.

Purpose: The purpose of this study was to determine the opinions and reported nutrition practices of Canadian Registered Dietitians (RDs) with regard to feeding patients with severe sepsis.

Methods: In 2017, surveys were sent to 112 eligible Canadian RDs in 10 provinces who were practicing in an intensive care environment. The survey included embedded branching logic questions developed to address major facets of sepsis, critical illness, and nutrition. The survey instrument assimilated all data in an anonymous manner, so respondents could not be linked to their answers.

Results: Of the 64 RDs who responded (57% response rate), the majority practiced in adult intensive care (81%), within an academic center (59%), and in a mixed unit (73%). A wide variability of Canadian RDs' opinions and practice was reported in determining energy requirements, enteral nutrition (EN) practice, EN with vasoactive agents, parenteral nutrition (PN), and supplemental micronutrients.

Conclusions: Practice variability of Canadian RDs likely reflects gaps in both evidence and guidelines for severe sepsis. Further research efforts are needed to customize nutritional requirements in the patient with evolving sepsis, EN with patients at high risk for gastrointestinal dysfunction, optimizing PN, and the role of micronutrients.
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http://dx.doi.org/10.3148/cjdpr-2018-029DOI Listing
March 2019

Utilizing Pediatric Scoring Systems to Predict Disposition During Interfacility Transport.

Prehosp Emerg Care 2019 Mar-Apr;23(2):249-253. Epub 2018 Aug 17.

Objective: Determining care disposition for pediatric patients during interfacility transport is often challenging. Severity of illness scoring can assist with this process. The purpose of this retrospective study was to compare currently utilized scoring systems and their ability to reliably match pediatric transport patients' severity of illness with the level of care necessary.

Methods: The retrospective transport registry review for our region included 209 patients <18 years, transported between 2015 and 2016 and admitted to tertiary care. The Pediatric RISk of Mortality III (PRISM III); Canadian Pediatric Triage and Acuity Scale (PedCTAS); Transport Pediatric Early Warning Scores (TPEWS); and Transport Risk Assessment in Pediatrics (TRAP) scores were calculated. Descriptive statistics and binomial logistic regression were utilized to compare the scoring tools. Interrater reliability was calculated using kappa statistics. All analyses were computed using IBM SPSS Statistics for Windows, version 24.

Results: Patients were more likely to be admitted to pediatric intensive care unit (PICU) with PedCTAS = 1 (odds ratio [OR] = 37.2; 95% confidence interval [CI], 12.4, 111.4; p < 0.0001), TPEWS = 3 in one category or total score ≥6 (OR = 42.2; 95% CI, 17.0, 104.9; p < 0.0001), and TRAP ≥4 (OR = 7.2; 95% CI, 3.8, 13.5; p < 0.0001). PRISM scores were not predictive for PICU admissions.

Conclusion: Elevated PedCTAS, TPEWS, and TRAP scores are strongly associated with PICU admission within the interfacility transport setting.
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http://dx.doi.org/10.1080/10903127.2018.1491658DOI Listing
July 2019

The Canadian Paediatric Triage and Acuity Scale algorithm for interfacility transport.

Am J Disaster Med 2018 ;13(1):57-63

Division of Pediatric Intensive Care, University of Saskatchewan, Saskatoon, Saskatchewan, Canada.

Objective: Determining pediatric severity of illness in referring centers may be useful for establishing appropriate patient disposition and interfacility transport. For this retrospective review, the authors evaluated the Canadian Paediatric Triage and Acuity Scale (PaedCTAS) tool in regards to individual patient disposition and outcomes.

Methods: A disposition score using the PaedCTAS algorithm was retrospectively calculated from referring center data at the time our transport team was consulted. Data included children < 17 years transported to our tertiary pediatric center between April 2013 and March 2014. Patients were excluded if transported because of elective or planned interventions, investigations, and/or treatment.

Results: A total of 194 pediatric patients were identified, with 49 requiring a pediatric intensive care unit (PICU) admission. A PaedCTAS assessment of 1 was the only transport characteristic evaluated that was significantly associated (odds ratio [OR] 6.15; p < 0.0001) with PICU admissions, with an area under the receiver-operating characteristic curve of 0.72 (95% CI 0.64, 0.77). On multivariate analysis, a PaedCTAS assessment of 1 was also associated with a length of hospital stay greater than 3 days (OR 1.81; 95% CI 0.99, 3.31; p = 0.05).

Conclusions: A PaedCTAS assessment of 1 may be a reasonable predictor for PICU admissions and longer hospitalizations when calculated in referral centers at time of pediatric transport consultation. PaedCTAS assessments may provide useful adjuvant information for specialized pediatric transport programs.
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http://dx.doi.org/10.5055/ajdm.2018.0282DOI Listing
August 2018

A Pediatric Case of Diffuse Alveolar Hemorrhage Secondary to Poststreptococcal Glomerulonephritis.

Case Rep Crit Care 2017 20;2017:1050284. Epub 2017 Dec 20.

Division of Pediatric Respirology, University of Saskatchewan, Saskatoon, SK, Canada.

This report summarizes a case of a 4-year-old girl with poststreptococcal glomerulonephritis and diffuse alveolar hemorrhage, an atypical presentation in this age group and type of vasculitic disease. We propose that her rapid improvement in clinical status was due to her treatment, continuous renal replacement therapy (CRRT). This mechanism would have impacted recovery by removing factors such as endothelial microparticles, superantigens, and immune complexes that have been postulated as the pulmonary-renal link. This may be an interesting avenue of exploration going forward given the lack of evidence in treating such conditions and emergence of CRRT.
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http://dx.doi.org/10.1155/2017/1050284DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5750514PMC
December 2017

Remote Presence Robotic Technology Reduces Need for Pediatric Interfacility Transportation from an Isolated Northern Community.

Telemed J E Health 2018 11 2;24(11):927-933. Epub 2018 Feb 2.

5 Department of Surgery, College of Medicine, University of Saskatchewan , Saskatoon, Canada .

Background: Providing acutely ill children in isolated communities access to specialized care is challenging. This study aimed to evaluate remote presence robotic technology (RPRT) for enhancing pediatric remote assessments, expediting initiation of treatment, refining triaging, and reducing the need for transport.

Methods: We conducted a pilot prospective observational study at a primary/urgent care clinic in an isolated northern community. Participants (n = 38) were acutely ill children <17 years presenting to the clinic, whom local healthcare professionals had considered for interfacility transportation (IFT). Participants were assessed and managed by a tertiary center pediatric intensivist through a remote presence robot. The intensivist triaged participants to either remain at the clinic or be transported to regional/tertiary care. Controls from a pre-existing local transport database were matched using propensity scoring. The primary outcome was the number of IFTs among participants versus controls.

Results: Fourteen of 38 (37%) participants required transport, whereas all controls were transported (p < 0.0001). Six of 14 (43%) transported participants were triaged to a nearby regional hospital, while no controls were regionalized (p = 0.0001). All participants who remained at the clinic stayed <24 h, and were matched to controls who stayed 4.9 days in tertiary care (p < 0.001). There was no statistically significant difference in hospital length of stay between transported participants and controls (6.0 vs. 5.7 days).

Conclusions: RPRT reduced the need for specialized pediatric IFT, while enabling regionalization when appropriate. This study may have implications for the broader implementation of RPRT, while reducing costs to the healthcare system.
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http://dx.doi.org/10.1089/tmj.2017.0211DOI Listing
November 2018

Hospital utilization for patients with amyotrophic lateral sclerosis in saskatoon, Canada.

Amyotroph Lateral Scler Frontotemporal Degener 2018 05 21;19(3-4):201-205. Epub 2017 Nov 21.

c Division of Neurology, Department of Medicine , University of Saskatchewan , Saskatoon , SK , Canada.

Objective: This retrospective study reviewed hospital and intensive care unit (ICU) admissions for patients with amyotrophic lateral sclerosis (ALS) in Saskatoon, Canada, between 2005 and 2017. The purpose was to understand hospital utilization and admission patterns for patients with ALS in the absence of coordinated multidisciplinary care.

Methods: Hospital/ICU admissions were detected at two hospitals in Saskatoon using the International Classification of Diseases (ICD-10) coding for ALS. Patient demographic data, hospitalization and pre-hospitalization information were recorded, and descriptive statistics were generated.

Results: Of the 83 patients identified, 52% were male with a mean age of 66.8 years. Fifty-two percent were undiagnosed prior to hospitalization, with significantly longer ICU stays compared to those diagnosed prior to admission (49.4 ± 46.6 vs. 21.9 ± 32.0 days; p = 0.0003). Eighty-nine percent of all admissions (n = 118) were non-elective. Although respiratory dysfunction was the most common reason for admission (n = 41, 49%), and all ICU admissions were for respiratory dysfunction, only 2% were on non-invasive ventilation prior to ICU admission. All tracheostomies (n =10, 12%) were placed non-electively, and 50% were in previously undiagnosed patients. Thirty-four percent (n = 28) of patients died in hospital in an ICU (n = 8, 29%) and hospital wards (n = 20, 71%).

Conclusion: ALS patients in Saskatoon had high non-elective admission rates, with over half undiagnosed prior to hospitalization, and high rates of emergent tracheostomy. This study highlights the need for early diagnosis and coordinated multidisciplinary care for improved outpatient management of ALS to reduce lengthy and complicated hospitalizations.
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http://dx.doi.org/10.1080/21678421.2017.1400071DOI Listing
May 2018

The effect of wedge and tibial slope angles on knee contact pressure and kinematics following medial opening-wedge high tibial osteotomy.

Clin Biomech (Bristol, Avon) 2018 01 2;51:17-25. Epub 2017 Nov 2.

Centre for Hip Health and Mobility, 2635 Laurel Street, Vancouver V5Z 1M9, BC, Canada; University of British Columbia, Department of Orthopaedics, 3114 - 910 West 10th Avenue, Vancouver V5Z 1M9, BC, Canada.

Background: High tibial osteotomy is a surgical procedure to treat medial compartment osteoarthritis in varus knees. The reported success rates of the procedure are inconsistent, which may be due to sagittal plane alignment of the osteotomy. The objective of this study was to determine the effect of changing tibial slope, for a range of tibial wedge angles in high tibial osteotomy, on knee joint contact pressure location and kinematics during continuous loaded flexion/extension.

Methods: Seven cadaveric knee specimens were cycled through flexion and extension in an Oxford knee-loading rig. The osteotomy on each specimen was adjusted to seven clinically relevant wedge and slope combinations. We used pressure sensors to determine the position of the centre of pressure in each compartment of the tibial plateau and infrared motion capture markers to determine tibiofemoral and patellofemoral kinematics.

Findings: In early knee flexion, a 5° increase in tibial slope shifted the centre of pressure in the medial compartment anteriorly by 4.5mm (P≤0.001), (from the neutral slope/wedge position). Increasing the tibial slope also resulted in the tibia translating anteriorly (P≤0.001).

Interpretation: Changes to the tibial slope during high tibial osteotomy for all tested wedge angles shifted the centre of pressure in both the medial and lateral compartments substantially and altered knee kinematics. Tibial slope should be controlled during high tibial osteotomy to prevent unwanted changes in tibial plateau contact loads.
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http://dx.doi.org/10.1016/j.clinbiomech.2017.10.021DOI Listing
January 2018

Mobile emergency simulation training for rural health providers.

Rural Remote Health 2017 Jul-Sep;17(3):4057. Epub 2017 Oct 17.

Division of Pediatric Intensive Care, Saskatoon, Saskatchewan, Canada.

Introduction: Mobile emergency simulation offers innovative continuing medical educational support to regions that may lack access to such opportunities. Furthermore, satisfaction is a critical element for active learning. Together, the authors evaluated Canadian rural healthcare providers' satisfaction from high fidelity emergency simulation training using a modified motorhome as a mobile education unit (MEU).

Methods: Over a 5-month period, data was collected during 14 educational sessions in nine different southern Manitoban communities. Groups of up to five rural healthcare providers managed emergency simulation cases including polytrauma, severe sepsis, and inferior myocardial infarction with right ventricular involvement, followed by a debrief. Participants anonymously completed a feedback form that contained 11 questions on a five-point Likert scale and six short-answer questions.

Results: Data from 131 respondents were analyzed, for a response rate of 75.6%. Respondents included nurses (27.5%), medical residents (26.7%), medical first responders (16.0%), and physicians (12.2%). The median response was 5 for overall quality of learning, development of clinical reasoning skills and decision-making ability, recognition of patient deterioration, and self-reflection. The post-simulation debrief median response was also 5 for summarizing important issues, constructive criticism, and feedback to learn. Respondents also reported that the MEU provided a believable working environment (87.0%, n=114), they had limited or no previous access to high fidelity mannequins (82.7%, n=107), and they had no specific training in crisis resource management or were unfamiliar with the term (92%, n=118).

Conclusions: A high level of satisfaction was reported in rural health providers with mobile emergency simulation. Access to and experience with high fidelity mannequins was limited, suggesting areas for potential educational growth.
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http://dx.doi.org/10.22605/RRH4057DOI Listing
February 2018

Prehospital Management of Acute Stroke in Rural versus Urban Responders.

J Neurosci Rural Pract 2017 Aug;8(Suppl 1):S33-S36

Department of Medicine, Health Sciences Centre, Section of Neurology, University of Manitoba, Winnipeg, Manitoba R3A 1R9, Canada.

Objective: Stroke guideline compliance of rural Canadian prehospital emergency medical services (EMS) care in acute stroke is unknown. In this quality assurance study, we sought to compare rural and urban care by prehospital EMS evaluation/management indicators from patients assessed at an urban Canadian stroke center.

Materials And Methods: One hundred adult patients were randomly selected from the stroke registry. Patients were transported through Rural EMS bypass protocols or urban EMS protocols (both bypass and direct) to our stroke center between January and December 2013. Patients were excluded if they were first evaluated at any other health center. Prehospital care was assessed using ten indicators for EMS evaluation/management, as recommended by acute stroke guidelines.

Results: Compliance with acute stroke EMS evaluation/management indicators were statistically similar for both groups, except administrating a prehospital diagnostic tool (rural 31.8 vs. urban 70.3%; = 0.002). Unlike urban EMS, rural EMS did not routinely document scene time.

Conclusion: Rural EMS responders' compliance to prehospital stroke evaluation/management was similar to urban EMS responders. Growth areas for both groups may be with prehospital stroke diagnostic tool utilization, whereas rural EMS responders may also improve with scene time documentation.
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http://dx.doi.org/10.4103/jnrp.jnrp_2_17DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5602258PMC
August 2017

Mechanical ventilation guided by electrical impedance tomography in pediatric acute respiratory distress syndrome.

J Clin Monit Comput 2018 Jun 20;32(3):503-507. Epub 2017 Jul 20.

Division of Pediatric Intensive Care, University of Saskatchewan, Saskatoon, Canada.

Mechanical ventilation strategies in pediatric acute respiratory distress syndrome (pARDS) continue to advance. Optimizing positive end expiratory pressure (PEEP) and ventilation to recruitable lung can be difficult to clinically achieve. This is in part, due to disease evolution, unpredictable changes in lung compliance, and the inability to assess regional tidal volumes in real time at the bedside. Here we report the utilization of thoracic electrical impedance tomography to guide daily PEEP settings and recruitment maneuvers in a child with pARDS.
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http://dx.doi.org/10.1007/s10877-017-0048-5DOI Listing
June 2018
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