BACKGROUND: Increased interest in implementing evidence-based medicine in paediatric practice has... more BACKGROUND: Increased interest in implementing evidence-based medicine in paediatric practice has led to the development of a variety of electronic clinical and decision-making support tools. Electronic medical records and information resources have the potential to improve both the clinical and cost effectiveness of paediatric community practice at the point of care. Barriers to the successful implementation of clinical information Intranet resources include physician attitudes, as well as system and practitioner capabilities. OBJECTIVE: To examine Ontario's community care paediatricians' electronic information resource needs and interest in accessing the proposed Central West Ontario Pediatric Information Network (CWPIN). DESIGN: Cross-sectional, interviewer-facilitated, structured survey. POPULATION STUDIED: Paediatricians providing community care in the Central West Ontario Health Region. MAIN RESULTS: Three-quarters of regional community paediatricians responded to the survey. Of those surveyed, 98% expressed interest in gaining access to the CWPIN. Computer literacy, suggested by home computer and Internet use rates (88% and 81%, respectively), did not differ significantly by age or sex. Other factors that may affect network use, such as workplace computer use and allied personnel role assignment, differed by sex, indicating potentially greater CWPIN use among male practitioners. CONCLUSIONS: Physicians reported an overwhelming interest in gaining access to and using the CWPIN. Disparities in current workplace but not home-based computer use by sex indicate that workplace role allocation, rather than computer literacy, may explain sex differences in CWPIN use rates. Attitudinal and computer proficiency issues did not appear to be obstacles to implementing the clinical information Intranet resource in the region.
Journal of the Canadian Association of Gastroenterology, 2022
Background Transitioning from pediatric to adult health care is associated with significant psych... more Background Transitioning from pediatric to adult health care is associated with significant psychosocial and clinical morbidity. Adolescents not only transition their medical care, but also experience vast changes in the physical, social, and psychological spheres of their lives. The medical team must help navigate these changes to provide optimal care. IBD in adolescence is associated with increased hospitalizations and surgery. This is due to several factors, including medication non-adherence and a failure to attend medical appointments. There has been a greater focus on improving care for this unique population. McMaster Children’s Hospital has integrated the AYA IBD clinic for patients between the ages of 16 and 22. The goal is to transition patients using a developmentally appropriate framework to facilitate self-efficacy and help identify comorbid mental health conditions while building resilience. Aims To explore the impact of the implementation of a dedicated transition cli...
Alternative health practices have become increasingly popular in recent years. Many patients visi... more Alternative health practices have become increasingly popular in recent years. Many patients visit specific complementary practitioners, while others attempt to educate themselves, trusting advice from employees at local health food stores or the Internet. Thirty-two retail health food stores were surveyed on the nature of the information provided by their staff. A research assistant visited the stores and presented as the mother of a child in whom Crohn’s disease had been diagnosed. Seventy-two per cent (23 of 32) of store employees offered advice, such as to take nutritional and herbal supplements. Of the 23 stores where recommendations were made, 15 (65%) based their recommendation on a source of information. Fourteen of the 15 stores using information sources used the same reference book. This had a significant impact on the recommendations; the use of nutritional supplements was favoured. In conclusion, retail health food stores are not as inconsistent as hypothesized, although...
Chronic recurrent multifocal osteomyelitis (CRMO) is a rare disease of children characterized by ... more Chronic recurrent multifocal osteomyelitis (CRMO) is a rare disease of children characterized by aseptic inflammation of the long bones and clavicles. No infectious etiology has been identified, and CRMO has been associated with a number of autoimmune diseases (including Wegener's granulomatosis and psoriasis). The relationship between CRMO and inflammatory bowel disease is poorly described. Through an internet bulletin board subscribed to by 500 pediatric gastroenterologists, we identified six inflammatory bowel disease patients (two with ulcerative colitis, four with Crohn's colitis) with confirmed CRMO. In all cases, onset of the bony lesions preceded the onset of bowel symptoms by as much as five years. Immunosuppressive therapy for the bowel disease generally resulted in improvement of the bone inflammation. Chronic recurrent multifocal osteomyelitis should be considered in any inflammatory bowel disease patient with unexplained bone pain or areas of uptake on bone scan...
Wolters Kluwer Health may email you for journal alerts and information, but is committed to maint... more Wolters Kluwer Health may email you for journal alerts and information, but is committed to maintaining your privacy and will not share your personal information without your express consent. For more information, please refer to our Privacy Policy. ... An abstract is unavailable. This article is ...
The safety and tolerance of energy-dense enteral pediatric formulae were evaluated and compared w... more The safety and tolerance of energy-dense enteral pediatric formulae were evaluated and compared with a standard formula. Children aged 1-6 years requiring tube feedings to provide ≥ 75% of their daily estimated energy needs for 21 days were evaluated in this phase III, randomized, open-label, multicenter study. Subjects received a control formula, Pediasure® (C; 1.0 kcal/mL) or an experimental formula similar in nutrient composition but higher in caloric density (1.5 kcal/mL) with or without fiber (EF and E, respectively). Subjects (n=94) returned for 3 weekly visits. Gastrointestinal parameters improved (p<0.05) in all groups. Energy intake was comparable among groups, but was achieved with lower (p<0.0001) volumes in E and EF relative to C. Weight gain was greater (p<0.01) in E versus C. Adverse event reporting was similar among groups. Energy dense formulae are an option for children with fluid restrictions or increased energy or fiber needs without compromising safety o...
Cannabis is commonly used in cyclic vomiting syndrome (CVS) due to its antiemetic and anxiolytic ... more Cannabis is commonly used in cyclic vomiting syndrome (CVS) due to its antiemetic and anxiolytic properties. Paradoxically, chronic cannabis use in the context of cyclic vomiting has led to the recognition of a putative new disorder called cannabinoid hyperemesis syndrome (CHS). Since its first description in 2004, numerous case series and case reports have emerged describing this phenomenon. Although not pathognomonic, a patient behavior called "compulsive hot water bathing" has been associated with CHS. There is considerable controversy about how CHS is defined. Most of the data remain heterogenous with limited follow-up, making it difficult to ascertain whether chronic cannabis use is causal, merely a clinical association with CVS, or unmasks or triggers symptoms in patients inherently predisposed to develop CVS. This article will discuss the role of cannabis in the regulation of nausea and vomiting, specifically focusing on both CVS and CHS, in order to address controversies in this context. To this objective, we have collated and analyzed published case series and case reports on CHS in order to determine the number of reported cases that meet current Rome IV criteria for CHS. We have also identified limitations in the existing diagnostic framework and propose revised criteria to diagnose CHS. Future research in this area should improve our understanding of the role of cannabis use in cyclic vomiting and help us better understand and manage this disorder.
Background: This evidence review was conducted to inform the accompanying clinical practice guide... more Background: This evidence review was conducted to inform the accompanying clinical practice guideline on the management of cyclic vomiting syndrome (CVS) in adults. Methods: We followed the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) framework and focused on interventions aimed at prophylactic management and abortive treatment of adults with CVS. Specifically, this evidence review addresses the following clinical questions: (a) Should the following pharmacologic agents be used for prophylaxis of CVS: amitriptyline, topiramate, aprepitant, zonisamide/levetiracetam, or mitochondrial supplements? (b) Should the following pharmacologic agents be used for abortive treatment: triptans or aprepitant? Results: We found very low-quality evidence to support the use of the following agents for prophylactic and abortive treatment of CVS: amitriptyline, topiramate, aprepitant, zonisamide/levetiracetam, and mitochondrial supplements. We have moderate certainty of evidence for the use of triptans as abortive therapy. We found limited evidence to support the use of ondansetron and the treatment of co-morbid conditions and complementary therapies. Conclusions: This evidence review helps inform the accompanying guideline for the management of adults with CVS which is aimed at helping clinicians, patients, and policymakers, and should improve patient outcomes. K E Y W O R D S cyclic vomiting, technical review, treatment This is an open access article under the terms of the Creat ive Commo ns Attri butio n-NonCo mmerc ial-NoDerivs License, which permits use and distribution in any medium, provided the original work is properly cited, the use is non-commercial and no modifications or adaptations are made.
Cyclic vomiting syndrome (CVS) is characterized by severe episodic emesis in adults and children.... more Cyclic vomiting syndrome (CVS) is characterized by severe episodic emesis in adults and children. Cannabinoid hyperemesis syndrome is an increasingly recognized CVSlike illness that has been associated with chronic cannabis use. There are significant gaps in our understanding of the pathophysiology, clinical features, comorbidities, and effective management options of CVS. Recommendations for treating CVS are based on limited clinical data, as no placebo-controlled, randomized trials have yet been conducted. Diseases associated with CVS, including migraine, mitochondrial disorders, autonomic dysfunction, and psychiatric comorbidities, provide clues about pathophysiologic mechanisms and suggest potential therapies. We review our current understanding of CVS and propose future research directions with the aim of developing effective therapy. Establishing a multicenter, standardized registry of CVS patients could drive research on multiple fronts including developing CVS-specific outcome measures to broaden our understanding of clinical profiles, to serve as treatment end points in clinical trials, and to provide a platform for patient recruitment for randomized clinical trials. Such a robust database would also facilitate conduct of research that aims to determine the underlying pathophysiological mechanisms and genetic basis for CVS, as well as identifying potential biomarkers for the disorder. Soliciting government and industry support is crucial to establishing the necessary infrastructure and achieving these goals. Patient advocacy groups such as the Cyclic Vomiting Syndrome Association (CVSA), which partner with clinicians and researchers to disseminate new information, to promote ongoing interactions between patients, their families, clinicians, investigators, to support ongoing CVS research and education, must be an integral part of this endeavor.
The increasing recognition of cyclic vomiting syndrome (CVS) in adults prompted the developmentof... more The increasing recognition of cyclic vomiting syndrome (CVS) in adults prompted the developmentoftheseevidence-basedguidelinesonthemanagementofCVSinadults, whichwassponsoredbytheAmericanNeurogastroenterologyandMotilitySociety (ANMS) and the Cyclic Vomiting Syndrome Association (CVSA). GRADE (Grading of Recommendations, Assessment, Development, and Evaluation) framework was usedandaprofessionallibrarianperformedtheliteraturesearch.Theexpertcom-mitteeincludedthePresidentoftheCVSAwhobroughtapatientperspectiveinto the deliberations. The committee makes recommendations for the prophylaxis of CVS, treatment of acute attacks, diagnosis, and overall management of CVS. The committeestronglyrecommendsthatadultswithmoderate-to-severeCVSreceive a tricyclic antidepressant (TCA), such as amitriptyline, as a first-line prophylactic medication and receive topiramate or aprepitant as alternate prophylactic medications.Zonisamideorlevetiracetamandmitochondrialsupplements(CoenzymeQ10, L-carnitine,andriboflavin)areconditionallyrecommendedasalternateprophylactic medications,eitheraloneorconcurrentlywithotherprophylacticmedications.For acuteattacks,thecommitteeconditionallyrecommendsusingserotoninantagonists, such as ondansetron, and/or triptans, such as sumatriptan or aprepitant to abort symptoms. Emergency department treatment is best achieved with the use of an individualizedtreatmentprotocolandsharedwiththecareteam(exampleprovided). The committee recommended screening and treatment for comorbid conditions such asanxiety,depression,migraineheadache,autonomicdysfunction,sleepdisorders, and substance use with referral to appropriate allied health services as indicated.
Canadian journal of gastroenterology & hepatology, 2017
The current number of healthcare providers (HCP) caring for children with inflammatory bowel dise... more The current number of healthcare providers (HCP) caring for children with inflammatory bowel disease (IBD) across Canadian tertiary-care centres is underinvestigated. The aim of this survey was to assess the number of healthcare providers (HCP) in ambulatory pediatric IBD care across Canadian tertiary-care centres. Using a self-administered questionnaire, we examined available resources in academic pediatric centres within the Canadian Children IBD Network. The survey evaluated the number of HCP providing ambulatory care for children with IBD. All 12 tertiary pediatric gastroenterology centres participating in the network responded. Median full-time equivalent (FTE) of allied health professionals providing IBD care at each site was 1.0 (interquartile range (IQR) 0.6-1.0) nurse, 0.5 (IQR 0.2-0.8) dietitian, 0.3 (IQR 0.2-0.8) social worker, and 0.1 (IQR 0.02-0.3) clinical psychologists. The ratio of IBD patients to IBD physicians was 114 : 1 (range 31 : 1-537 : 1), patients to nurses/...
Canadian journal of gastroenterology & hepatology, Jan 15, 2015
The treatment armamentarium in pediatric Crohn disease (CD) is very similar to adult-onset CD wit... more The treatment armamentarium in pediatric Crohn disease (CD) is very similar to adult-onset CD with the notable exception of the use of exclusive enteral nutrition (EEN [the administration of a liquid formula diet while excluding normal diet]), which is used more frequently by pediatric gastroenterologists to induce remission. In pediatric CD, EEN is now recommended by the pediatric committee of the European Crohn's and Colitis Organisation and the European Society for Paediatric Gastroenterology Hepatology and Nutrition as a first-choice agent to induce remission, with remission rates in pediatric studies consistently >75%. To chart and address enablers and barriers of use of EEN in Canada, a workshop was held in September 2014 in Toronto (Ontario), inviting pediatric gastroenterologists, nurses and dietitians from most Canadian pediatric IBD centres as well as international faculty from the United States and Europe with particular research and clinical expertise in the dieta...
P aediatrics & Child Health is a publication that serves as a means of communication, a documenta... more P aediatrics & Child Health is a publication that serves as a means of communication, a documentary record, and the voice of the Canadian Paediatric Society (CPS). Moreover, by design, it is a tool for improving the health and health care of children and youth in Canada. Recently, the editor-in-chief asked the CPS Board to initiate a review to see if Paediatrics & Child Health was "on target". Did it meet the mission that had been established for it? Was it meeting the needs of the readers and the needs of the society of professionals that sponsors it? The CPS was fortunate to be able to engage Dr Robert Haggerty for this external review.
Canadian journal of gastroenterology = Journal canadien de gastroenterologie, 2013
Wait times are an important measure of health care system effectiveness. There are no studies des... more Wait times are an important measure of health care system effectiveness. There are no studies describing wait times in pediatric gastroenterology for either outpatient visits or endoscopy. Pediatric endoscopy is performed under light sedation or general anesthesia. The latter is hypothesized to be associated with a longer wait time due to practical limits on access to anesthesia in the Canadian health care system. To identify wait time differences according to sedation type and measure adverse clinical outcomes that may arise from increased wait time to endoscopy in pediatric patients. The present study was a retrospective review of medical charts of all patients <18 years of age who had been assessed in the pediatric gastroenterology clinic and were scheduled for an elective outpatient endoscopic procedure at McMaster Children's Hospital (Hamilton, Ontario) between January 2006 and December 2007. The primary outcome measure was time between clinic visit and date of endoscopy...
The objectives of this study were to (i) assess sedentary time and prevalence of screen-based sed... more The objectives of this study were to (i) assess sedentary time and prevalence of screen-based sedentary behaviours of children with a chronic disease and (ii) compare sedentary time and prevalence of screen-based sedentary behaviours to age- and sex-matched healthy controls. Sixty-five children (aged 6-18 years) with a chronic disease participated: survivors of a brain tumor, haemophilia, type 1 diabetes mellitus, juvenile idiopathic arthritis, cystic fibrosis and…
Objectives To assess vitamin D status of pediatric patients with Crohn's disease (CD) and to comp... more Objectives To assess vitamin D status of pediatric patients with Crohn's disease (CD) and to compare their serum 25-hydroxyvitamin D (s-25OHD) with established cutoffs and assess whether 6 months of supplementation with 2000 IU/d, vs 400 IU/d, would reduce the group prevalence of vitamin D below these cutoffs. Study design Subjects 8-18 years (n = 83) with quiescent CD were randomized to either 400 or 2000 IU vitamin D 3 /d for 6 months. Results Baseline mean AE SD s-25OHD was 24 AE 8 ng/mL; 13 subjects (16%) had an s-25OHD <16 ng/mL, 27 (33%) < 20 ng/mL, and 65 (79%) < 30 ng/mL. There was no significant difference between groups in achieving the cutoffs of 16 ng/mL or 20 ng/mL at 6 months; however, only 35% of the 400 IU group achieved the greater cutoff of 30 ng/mL compared with 74% in the 2000 IU group (P < .001). Baseline adjusted mean s-25OHD concentrations at 6 months were 9.6 ng/mL (95% CI 6.0-13.2, P < .001) greater in the 2000 IU than the 400 IU group. Disease activity was not affected by supplement dose. Few subjects exceeded safety marker cutoffs, and this did not differ by dose. Conclusions At baseline, a high proportion of patients had a mean s-25OHD >20 ng/mL. 2000 IU vitamin D 3 /d is more effective in raising s-25OHD concentrations to > 30 ng/mL in children with CD than 400 IU/d, but both treatments were equally effective at achieving 16 or 20 ng/mL.
BACKGROUND: Increased interest in implementing evidence-based medicine in paediatric practice has... more BACKGROUND: Increased interest in implementing evidence-based medicine in paediatric practice has led to the development of a variety of electronic clinical and decision-making support tools. Electronic medical records and information resources have the potential to improve both the clinical and cost effectiveness of paediatric community practice at the point of care. Barriers to the successful implementation of clinical information Intranet resources include physician attitudes, as well as system and practitioner capabilities. OBJECTIVE: To examine Ontario's community care paediatricians' electronic information resource needs and interest in accessing the proposed Central West Ontario Pediatric Information Network (CWPIN). DESIGN: Cross-sectional, interviewer-facilitated, structured survey. POPULATION STUDIED: Paediatricians providing community care in the Central West Ontario Health Region. MAIN RESULTS: Three-quarters of regional community paediatricians responded to the survey. Of those surveyed, 98% expressed interest in gaining access to the CWPIN. Computer literacy, suggested by home computer and Internet use rates (88% and 81%, respectively), did not differ significantly by age or sex. Other factors that may affect network use, such as workplace computer use and allied personnel role assignment, differed by sex, indicating potentially greater CWPIN use among male practitioners. CONCLUSIONS: Physicians reported an overwhelming interest in gaining access to and using the CWPIN. Disparities in current workplace but not home-based computer use by sex indicate that workplace role allocation, rather than computer literacy, may explain sex differences in CWPIN use rates. Attitudinal and computer proficiency issues did not appear to be obstacles to implementing the clinical information Intranet resource in the region.
Journal of the Canadian Association of Gastroenterology, 2022
Background Transitioning from pediatric to adult health care is associated with significant psych... more Background Transitioning from pediatric to adult health care is associated with significant psychosocial and clinical morbidity. Adolescents not only transition their medical care, but also experience vast changes in the physical, social, and psychological spheres of their lives. The medical team must help navigate these changes to provide optimal care. IBD in adolescence is associated with increased hospitalizations and surgery. This is due to several factors, including medication non-adherence and a failure to attend medical appointments. There has been a greater focus on improving care for this unique population. McMaster Children’s Hospital has integrated the AYA IBD clinic for patients between the ages of 16 and 22. The goal is to transition patients using a developmentally appropriate framework to facilitate self-efficacy and help identify comorbid mental health conditions while building resilience. Aims To explore the impact of the implementation of a dedicated transition cli...
Alternative health practices have become increasingly popular in recent years. Many patients visi... more Alternative health practices have become increasingly popular in recent years. Many patients visit specific complementary practitioners, while others attempt to educate themselves, trusting advice from employees at local health food stores or the Internet. Thirty-two retail health food stores were surveyed on the nature of the information provided by their staff. A research assistant visited the stores and presented as the mother of a child in whom Crohn’s disease had been diagnosed. Seventy-two per cent (23 of 32) of store employees offered advice, such as to take nutritional and herbal supplements. Of the 23 stores where recommendations were made, 15 (65%) based their recommendation on a source of information. Fourteen of the 15 stores using information sources used the same reference book. This had a significant impact on the recommendations; the use of nutritional supplements was favoured. In conclusion, retail health food stores are not as inconsistent as hypothesized, although...
Chronic recurrent multifocal osteomyelitis (CRMO) is a rare disease of children characterized by ... more Chronic recurrent multifocal osteomyelitis (CRMO) is a rare disease of children characterized by aseptic inflammation of the long bones and clavicles. No infectious etiology has been identified, and CRMO has been associated with a number of autoimmune diseases (including Wegener's granulomatosis and psoriasis). The relationship between CRMO and inflammatory bowel disease is poorly described. Through an internet bulletin board subscribed to by 500 pediatric gastroenterologists, we identified six inflammatory bowel disease patients (two with ulcerative colitis, four with Crohn's colitis) with confirmed CRMO. In all cases, onset of the bony lesions preceded the onset of bowel symptoms by as much as five years. Immunosuppressive therapy for the bowel disease generally resulted in improvement of the bone inflammation. Chronic recurrent multifocal osteomyelitis should be considered in any inflammatory bowel disease patient with unexplained bone pain or areas of uptake on bone scan...
Wolters Kluwer Health may email you for journal alerts and information, but is committed to maint... more Wolters Kluwer Health may email you for journal alerts and information, but is committed to maintaining your privacy and will not share your personal information without your express consent. For more information, please refer to our Privacy Policy. ... An abstract is unavailable. This article is ...
The safety and tolerance of energy-dense enteral pediatric formulae were evaluated and compared w... more The safety and tolerance of energy-dense enteral pediatric formulae were evaluated and compared with a standard formula. Children aged 1-6 years requiring tube feedings to provide ≥ 75% of their daily estimated energy needs for 21 days were evaluated in this phase III, randomized, open-label, multicenter study. Subjects received a control formula, Pediasure® (C; 1.0 kcal/mL) or an experimental formula similar in nutrient composition but higher in caloric density (1.5 kcal/mL) with or without fiber (EF and E, respectively). Subjects (n=94) returned for 3 weekly visits. Gastrointestinal parameters improved (p<0.05) in all groups. Energy intake was comparable among groups, but was achieved with lower (p<0.0001) volumes in E and EF relative to C. Weight gain was greater (p<0.01) in E versus C. Adverse event reporting was similar among groups. Energy dense formulae are an option for children with fluid restrictions or increased energy or fiber needs without compromising safety o...
Cannabis is commonly used in cyclic vomiting syndrome (CVS) due to its antiemetic and anxiolytic ... more Cannabis is commonly used in cyclic vomiting syndrome (CVS) due to its antiemetic and anxiolytic properties. Paradoxically, chronic cannabis use in the context of cyclic vomiting has led to the recognition of a putative new disorder called cannabinoid hyperemesis syndrome (CHS). Since its first description in 2004, numerous case series and case reports have emerged describing this phenomenon. Although not pathognomonic, a patient behavior called "compulsive hot water bathing" has been associated with CHS. There is considerable controversy about how CHS is defined. Most of the data remain heterogenous with limited follow-up, making it difficult to ascertain whether chronic cannabis use is causal, merely a clinical association with CVS, or unmasks or triggers symptoms in patients inherently predisposed to develop CVS. This article will discuss the role of cannabis in the regulation of nausea and vomiting, specifically focusing on both CVS and CHS, in order to address controversies in this context. To this objective, we have collated and analyzed published case series and case reports on CHS in order to determine the number of reported cases that meet current Rome IV criteria for CHS. We have also identified limitations in the existing diagnostic framework and propose revised criteria to diagnose CHS. Future research in this area should improve our understanding of the role of cannabis use in cyclic vomiting and help us better understand and manage this disorder.
Background: This evidence review was conducted to inform the accompanying clinical practice guide... more Background: This evidence review was conducted to inform the accompanying clinical practice guideline on the management of cyclic vomiting syndrome (CVS) in adults. Methods: We followed the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) framework and focused on interventions aimed at prophylactic management and abortive treatment of adults with CVS. Specifically, this evidence review addresses the following clinical questions: (a) Should the following pharmacologic agents be used for prophylaxis of CVS: amitriptyline, topiramate, aprepitant, zonisamide/levetiracetam, or mitochondrial supplements? (b) Should the following pharmacologic agents be used for abortive treatment: triptans or aprepitant? Results: We found very low-quality evidence to support the use of the following agents for prophylactic and abortive treatment of CVS: amitriptyline, topiramate, aprepitant, zonisamide/levetiracetam, and mitochondrial supplements. We have moderate certainty of evidence for the use of triptans as abortive therapy. We found limited evidence to support the use of ondansetron and the treatment of co-morbid conditions and complementary therapies. Conclusions: This evidence review helps inform the accompanying guideline for the management of adults with CVS which is aimed at helping clinicians, patients, and policymakers, and should improve patient outcomes. K E Y W O R D S cyclic vomiting, technical review, treatment This is an open access article under the terms of the Creat ive Commo ns Attri butio n-NonCo mmerc ial-NoDerivs License, which permits use and distribution in any medium, provided the original work is properly cited, the use is non-commercial and no modifications or adaptations are made.
Cyclic vomiting syndrome (CVS) is characterized by severe episodic emesis in adults and children.... more Cyclic vomiting syndrome (CVS) is characterized by severe episodic emesis in adults and children. Cannabinoid hyperemesis syndrome is an increasingly recognized CVSlike illness that has been associated with chronic cannabis use. There are significant gaps in our understanding of the pathophysiology, clinical features, comorbidities, and effective management options of CVS. Recommendations for treating CVS are based on limited clinical data, as no placebo-controlled, randomized trials have yet been conducted. Diseases associated with CVS, including migraine, mitochondrial disorders, autonomic dysfunction, and psychiatric comorbidities, provide clues about pathophysiologic mechanisms and suggest potential therapies. We review our current understanding of CVS and propose future research directions with the aim of developing effective therapy. Establishing a multicenter, standardized registry of CVS patients could drive research on multiple fronts including developing CVS-specific outcome measures to broaden our understanding of clinical profiles, to serve as treatment end points in clinical trials, and to provide a platform for patient recruitment for randomized clinical trials. Such a robust database would also facilitate conduct of research that aims to determine the underlying pathophysiological mechanisms and genetic basis for CVS, as well as identifying potential biomarkers for the disorder. Soliciting government and industry support is crucial to establishing the necessary infrastructure and achieving these goals. Patient advocacy groups such as the Cyclic Vomiting Syndrome Association (CVSA), which partner with clinicians and researchers to disseminate new information, to promote ongoing interactions between patients, their families, clinicians, investigators, to support ongoing CVS research and education, must be an integral part of this endeavor.
The increasing recognition of cyclic vomiting syndrome (CVS) in adults prompted the developmentof... more The increasing recognition of cyclic vomiting syndrome (CVS) in adults prompted the developmentoftheseevidence-basedguidelinesonthemanagementofCVSinadults, whichwassponsoredbytheAmericanNeurogastroenterologyandMotilitySociety (ANMS) and the Cyclic Vomiting Syndrome Association (CVSA). GRADE (Grading of Recommendations, Assessment, Development, and Evaluation) framework was usedandaprofessionallibrarianperformedtheliteraturesearch.Theexpertcom-mitteeincludedthePresidentoftheCVSAwhobroughtapatientperspectiveinto the deliberations. The committee makes recommendations for the prophylaxis of CVS, treatment of acute attacks, diagnosis, and overall management of CVS. The committeestronglyrecommendsthatadultswithmoderate-to-severeCVSreceive a tricyclic antidepressant (TCA), such as amitriptyline, as a first-line prophylactic medication and receive topiramate or aprepitant as alternate prophylactic medications.Zonisamideorlevetiracetamandmitochondrialsupplements(CoenzymeQ10, L-carnitine,andriboflavin)areconditionallyrecommendedasalternateprophylactic medications,eitheraloneorconcurrentlywithotherprophylacticmedications.For acuteattacks,thecommitteeconditionallyrecommendsusingserotoninantagonists, such as ondansetron, and/or triptans, such as sumatriptan or aprepitant to abort symptoms. Emergency department treatment is best achieved with the use of an individualizedtreatmentprotocolandsharedwiththecareteam(exampleprovided). The committee recommended screening and treatment for comorbid conditions such asanxiety,depression,migraineheadache,autonomicdysfunction,sleepdisorders, and substance use with referral to appropriate allied health services as indicated.
Canadian journal of gastroenterology & hepatology, 2017
The current number of healthcare providers (HCP) caring for children with inflammatory bowel dise... more The current number of healthcare providers (HCP) caring for children with inflammatory bowel disease (IBD) across Canadian tertiary-care centres is underinvestigated. The aim of this survey was to assess the number of healthcare providers (HCP) in ambulatory pediatric IBD care across Canadian tertiary-care centres. Using a self-administered questionnaire, we examined available resources in academic pediatric centres within the Canadian Children IBD Network. The survey evaluated the number of HCP providing ambulatory care for children with IBD. All 12 tertiary pediatric gastroenterology centres participating in the network responded. Median full-time equivalent (FTE) of allied health professionals providing IBD care at each site was 1.0 (interquartile range (IQR) 0.6-1.0) nurse, 0.5 (IQR 0.2-0.8) dietitian, 0.3 (IQR 0.2-0.8) social worker, and 0.1 (IQR 0.02-0.3) clinical psychologists. The ratio of IBD patients to IBD physicians was 114 : 1 (range 31 : 1-537 : 1), patients to nurses/...
Canadian journal of gastroenterology & hepatology, Jan 15, 2015
The treatment armamentarium in pediatric Crohn disease (CD) is very similar to adult-onset CD wit... more The treatment armamentarium in pediatric Crohn disease (CD) is very similar to adult-onset CD with the notable exception of the use of exclusive enteral nutrition (EEN [the administration of a liquid formula diet while excluding normal diet]), which is used more frequently by pediatric gastroenterologists to induce remission. In pediatric CD, EEN is now recommended by the pediatric committee of the European Crohn's and Colitis Organisation and the European Society for Paediatric Gastroenterology Hepatology and Nutrition as a first-choice agent to induce remission, with remission rates in pediatric studies consistently >75%. To chart and address enablers and barriers of use of EEN in Canada, a workshop was held in September 2014 in Toronto (Ontario), inviting pediatric gastroenterologists, nurses and dietitians from most Canadian pediatric IBD centres as well as international faculty from the United States and Europe with particular research and clinical expertise in the dieta...
P aediatrics & Child Health is a publication that serves as a means of communication, a documenta... more P aediatrics & Child Health is a publication that serves as a means of communication, a documentary record, and the voice of the Canadian Paediatric Society (CPS). Moreover, by design, it is a tool for improving the health and health care of children and youth in Canada. Recently, the editor-in-chief asked the CPS Board to initiate a review to see if Paediatrics & Child Health was "on target". Did it meet the mission that had been established for it? Was it meeting the needs of the readers and the needs of the society of professionals that sponsors it? The CPS was fortunate to be able to engage Dr Robert Haggerty for this external review.
Canadian journal of gastroenterology = Journal canadien de gastroenterologie, 2013
Wait times are an important measure of health care system effectiveness. There are no studies des... more Wait times are an important measure of health care system effectiveness. There are no studies describing wait times in pediatric gastroenterology for either outpatient visits or endoscopy. Pediatric endoscopy is performed under light sedation or general anesthesia. The latter is hypothesized to be associated with a longer wait time due to practical limits on access to anesthesia in the Canadian health care system. To identify wait time differences according to sedation type and measure adverse clinical outcomes that may arise from increased wait time to endoscopy in pediatric patients. The present study was a retrospective review of medical charts of all patients <18 years of age who had been assessed in the pediatric gastroenterology clinic and were scheduled for an elective outpatient endoscopic procedure at McMaster Children's Hospital (Hamilton, Ontario) between January 2006 and December 2007. The primary outcome measure was time between clinic visit and date of endoscopy...
The objectives of this study were to (i) assess sedentary time and prevalence of screen-based sed... more The objectives of this study were to (i) assess sedentary time and prevalence of screen-based sedentary behaviours of children with a chronic disease and (ii) compare sedentary time and prevalence of screen-based sedentary behaviours to age- and sex-matched healthy controls. Sixty-five children (aged 6-18 years) with a chronic disease participated: survivors of a brain tumor, haemophilia, type 1 diabetes mellitus, juvenile idiopathic arthritis, cystic fibrosis and…
Objectives To assess vitamin D status of pediatric patients with Crohn's disease (CD) and to comp... more Objectives To assess vitamin D status of pediatric patients with Crohn's disease (CD) and to compare their serum 25-hydroxyvitamin D (s-25OHD) with established cutoffs and assess whether 6 months of supplementation with 2000 IU/d, vs 400 IU/d, would reduce the group prevalence of vitamin D below these cutoffs. Study design Subjects 8-18 years (n = 83) with quiescent CD were randomized to either 400 or 2000 IU vitamin D 3 /d for 6 months. Results Baseline mean AE SD s-25OHD was 24 AE 8 ng/mL; 13 subjects (16%) had an s-25OHD <16 ng/mL, 27 (33%) < 20 ng/mL, and 65 (79%) < 30 ng/mL. There was no significant difference between groups in achieving the cutoffs of 16 ng/mL or 20 ng/mL at 6 months; however, only 35% of the 400 IU group achieved the greater cutoff of 30 ng/mL compared with 74% in the 2000 IU group (P < .001). Baseline adjusted mean s-25OHD concentrations at 6 months were 9.6 ng/mL (95% CI 6.0-13.2, P < .001) greater in the 2000 IU than the 400 IU group. Disease activity was not affected by supplement dose. Few subjects exceeded safety marker cutoffs, and this did not differ by dose. Conclusions At baseline, a high proportion of patients had a mean s-25OHD >20 ng/mL. 2000 IU vitamin D 3 /d is more effective in raising s-25OHD concentrations to > 30 ng/mL in children with CD than 400 IU/d, but both treatments were equally effective at achieving 16 or 20 ng/mL.
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Papers by R. Issenman