Roger Chafe

The rise of people power

Calls in Canada for trials of a contentious treatment for multiple sclerosis illustrate how social media can affect research priorities, say Roger Chafe and his colleagues.

Incidence and cohort prevalence for autism spectrum disorders in the Avalon Peninsula, Newfoundland and Labrador.

BACKGROUNDnRecent studies have reported increased prevalence for autism spectrum disorders in a number of geographical locations. Our objective was to determine the incidence and 1-year cohort prevalence for autism spectrum disorders in children less than 15 years of age and living in the Avalon Peninsula at the time of diagnosis.nnnMETHODSnRetrospective and prospective data were obtained from the Janeway Childrens Health and Rehabilitation Centre (St. Johns), including the identification and specific diagnosis for all children assessed for autism spectrum disorder from 2006 to 2010. Additional clinic data were reviewed to update the data until the end of 2013.nnnRESULTSnFrom 2006 to 2010, 272 children had a diagnosis of autism spectrum disorder, averaging 54 new cases per year. The incidence of new cases increased from 10.1 to 16.7 cases per 10 000 per year from 2006 to 2010. At the end of 2013, the prevalence among children born in 2006 was 1 case of autism spectrum disorder per 46 children or 215.77 per 10 000.nnnINTERPRETATIONnWe found higher rates of autism spectrum disorder than previously reported for this population. The prevalence in this region is also high when compared with other global populations. The high rate of diagnosis supports the need for a provincial autism spectrum disorder registry and further research on autism spectrum disorder within this population.

Delayed diagnosis and issues with pump usage are the leading causes of diabetic ketoacidosis in children with diabetes living in Newfoundland and Labrador, Canada

BackgroundNewfoundland and Labrador (NL) has a very high incidence of type 1 diabetes (T1DM) and admission rate for diabetic ketoacidosis (DKA). The purpose of this study was to identify characteristics and precipitating factors associated with pediatric DKA in this population.MethodsThis was a retrospective study on children diagnosed with DKA from 2007–2011 admitted to the province’s only tertiary care pediatric hospital. Demographics, biochemical characteristics, and reasons for DKA diagnosis were analyzed. Chi-square and Fisher Exact tests were performed for categorical variables; t- and non-parametric Kruskal-Wallis tests were performed for continuous variables.ResultsA total of 90 children were admitted with DKA (39.5% newly diagnosed; 60.5% were previously diagnosed). The rate of DKA on presentation for incident cases was 22.1%. More severe cases of DKA occurred in younger, newly diagnosed patients. Almost half of preexisting diabetes cases were recurrent DKA (49.1%). The most common presenting characteristics of newly diagnosed patients were weight loss, bedwetting, polyuria, polydipsia, and neurologic symptoms. Pre-existing diabetes patients most often presented with abdominal pain and vomiting. Diagnosis of diabetes in new patients and issues related to interrupted insulin delivery in pre-existing patients using insulin pump therapy were the most common factors associated with DKA. Of the newly diagnosed patients presenting in DKA, 64% had seen a physician in the weeks leading up to diagnosis.ConclusionsPediatric patients have predictable patterns associated with a diagnosis of DKA. Most cases of DKA could be prevented with earlier diagnosis and improved education and problem-solving by families and health care providers. DKA preventative strategies are recommended and should be aimed at patients, their families, and health care professionals especially those outside of pediatric centers.

Poor access to timely pain reduction interventions for pediatric patients with supracondylar humerus fracture.

Objective The purpose of this study was to describe the use of analgesic interventions in children with acute supracondylar fractures presenting to a pediatric emergency department (ED) and to explore the relationship between timely interventions and severity of injury. Methods This was a retrospective cohort study. Structured chart reviews were conducted on all eligible cases of acute supracondylar humerus fracture presenting to a single pediatric ED over a 5-year period ending in December 2009. Two interventions were studied: administration of a systemic analgesic and placement of an immobilizing backslab. Criteria for timeliness were administration of an analgesic within 30 minutes from triage and placement of a backslab before radiography. Cases were dichotomized as nonsevere or severe based on whether the fracture was treated with casting alone or with another orthopedic intervention (closed reduction in the ED or any procedure in the operating room). Results Of 160 eligible cases, 116 were classified as nonsevere and 44 as severe. The proportions receiving a timely analgesic were 3% and 11%, respectively, in these groups (P = 0.04 for difference). For backslab application, 16% and 61% received timely treatment in the nonsevere and severe groups, respectively (P = 0.000 for difference). Conclusions Children presenting to a pediatric ED with a painful injury had low access to early systemic analgesics and backslab immobilization. Many factors may have played a role, including lack of mandated documentation of a formal pain score and lack of a medical directive allowing triage nurses to administer analgesics in the institution studied.

Reducing episodes of diabetic ketoacidosis within a youth population: a focus group study with patients and families

BackgroundDiabetic ketoacidosis (DKA) is the most common cause of morbidity and mortality for youth with type 1 diabetes mellitus (T1DM). This article reports qualitative data from focus groups with youth and parents of youth with T1DM on the barriers that they identify to DKA prevention and resources that may aid youth better manage their diabetes.MethodsFour focus groups were held in three communities, two rural and one urban, in the Canadian province of Newfoundland and Labrador (NL) with adolescents and parents of youth with diabetes. Open-ended questions focused on knowledge of DKA, diabetes education, personal experiences with DKA, barriers to diabetes self-management, situations which put them at risk for DKA and resources that could be developed to aid youth in preventing DKA.ResultsThere were 19 participants (14 parents and 5 youth). Participants identified factors which increased their risk of DKA as difficulty in distinguishing cases of DKA from other illnesses; variations in diabetes education received; information overload about their condition; the long period from initial diagnosis, when most education about the condition was received; and stress regarding situations where youth are not in the direct care of their parents. Participants from rural areas reported geographical isolation and lack of regular access to specialist health care personnel as additional barriers to better diabetes management.ConclusionsThe project identified barriers to DKA prevention for youth which were not previously identified in the medical literature, e.g., the stress associated with temporary guardians, risk of information overload at initial diagnosis and the long period from initial diagnosis when most diabetes education is received. Families from rural areas do report additional burdens, but in some cases these families have developed community supports to help offset some of these problems. Mobile and online resources, educational refreshers about DKA, concise resources for teachers and other temporary guardians, and DKA treatment kits for parents may help improve diabetes management and prevent future episodes of DKA.

Association of type 1 diabetes and concentrations of drinking water components in Newfoundland and Labrador, Canada

Objective To determine the association between drinking water quality and rates of type 1 diabetes in the Newfoundland and Labrador (NL) population, which has one of the highest incidences of type 1 diabetes reported globally. Research design and methods The study used a community-based, case-control design. We first calculated incidence rates of type 1 diabetes at the provincial, regional and community levels. The connection between incidence rates and components in public water supplies were then analyzed in three ways: to evaluate differences in water quality between communities with and without incident cases of type 1 diabetes, and to analyze the relationship between water quality and incidence rates of type 1 diabetes at both the community and regional levels. Results The provincial incidence of type 1 diabetes was 51.7/100 000 (0-14 year age group) for the period studied. In the community-based analysis, there were significant associations found between higher concentrations of arsenic (β=0.268, P=0.013) and fluoride (β=0.202, P=0.005) in drinking water and higher incidence of type 1 diabetes. In the regional analysis, barium (β=−0.478, P=0.009) and nickel (β=−0.354, P=0.050) concentrations were negatively associated with incidence of type 1 diabetes. Conclusions We confirmed the high incidence of type 1 diabetes in NL. We also found that concentrations of some components in drinking water were associated with higher incidence of type 1 diabetes, but no component was found to have a significant association across the three different levels of analysis performed.

Improving the Treatment and Assessment of Moderate and Severe Pain in a Pediatric Emergency Department

Background. The Janeway Childrens Hospital previously enacted a number of measures to improve pain management for patients in its emergency department (ED). While improvements were demonstrated, rates for the timely assessment and treatment of pain remain below standards of care. Objectives. The study objectives are to investigate the impact of the previous attempts to improve the treatment of pain and to explore ways to further improve pain management in the ED. Methods. Key informant interviews and a focus group were conducted with nurses, physicians, and parents whose children were identified as having severe pain. Results. Interviews were conducted with 31 parents or children, 9 physicians, and 8 nurses. The focus group was attended by 15 nurses. Previous initiatives were viewed as improvements. Continued barriers include difficulties in accurately capturing the level of pain, issues in treating pain for specific types of patients, and inadequacy in addressing patients in severe pain. Conclusion. Changes in pain treatment protocols can result in positive impacts but are likely insufficient on their own to achieve desired standards of care. Consistent measurement and engagement with staff can identify additional opportunities for improving pain management within an ED setting.

Multiple interventions improve analgesic treatment of supracondylar fractures in a pediatric emergency department

Appropriate emergency room treatment of supracondylar humerus fractures in children includes timely administration of analgesia and backslab immobilization before radiography. This study assessed the effect of the implementation of a formal triage pain assessment and treatment medical directive for nurses and physicians in a pediatric emergency room setting.

Hospitalizations due to self-poisoning at a Canadian paediatric hospital

BackgroundnAdolescent self-harm by drug ingestion (i.e., self-poisoning) is a serious mental health issue. In Newfoundland and Labrador (NL), paediatricians suspected an increase in the number of adolescents hospitalized due to self-poisoning in the province. Our primary aim was to evaluate the number of hospital admissions of adolescents for self-poisoning between 2008 and 2013 to determine whether there was indeed an increase in hospitalizations. We also wanted to examine the characteristics of these admissions to better understand this patient population.nnnMethodnA retrospective chart review was conducted to identify cases of self-poisoning admitted to the only paediatric hospital in NL over a 6-year period. A data abstraction form was developed to collect patient demographic information and details about these incidences of self-poisoning.nnnResultsnA total of 156 patient admissions were identified; 97 (62.2%) first time admissions and 59 (37.8%) recurrent admissions. The number of admissions for self-poisoning increased over the study period from 2.1% of total hospital admissions in 2008 to 6.5% in 2013. Mean (SD) age at the time of admission was 15.4 years, 122 patients (78.2%) were female and 86.5% had at least 1 previous mental health diagnosis. The most common drugs ingested were analgesics (38.0%) and antidepressants (32.2%), with 73 patients (48.7%) ingesting multiple drugs.nnnConclusionsnThe study contributes to the growing recognition of adolescent self-poisoning as a serious paediatric mental health issue. It also confirmed that an increase in adolescent hospitalizations due to self-poisoning has occurred in NL. Further research is warranted to identify effective prevention strategies for this serious problem.