Objectives An eight-bed adult coronavirus (COVID-19) critical care (CC) unit was established with... more Objectives An eight-bed adult coronavirus (COVID-19) critical care (CC) unit was established within our pediatric CC unit (PCCU) when SARS-CoV-2 (severe acute respiratory syndrome coronavirus 2) variants increased the CC bed demand. Our objective was to rapidly implement electronic order sets (OSs) to facilitate computerized provider order entry (CPOE) for adult patients admitted within a children's hospital. Methods OS development began from the assessment of OSs from seven adult CC units. Using a pre-existing PCCU admission template, we created two OSs: adult COVID-19 admission and ongoing care. We tested the prototypes in a multidisciplinary onsite–virtual hybrid tabletop simulation to evaluate usability within established workflows. Participants utilized role-specific profiles within the electronic health record (EHR) training environment which paralleled their computer interface, permitting charting and documentation. EHR analysts were present to gather change requests. Fol...
Clinicians caring for neonates with congenital heart disease encounter challenges in clinical car... more Clinicians caring for neonates with congenital heart disease encounter challenges in clinical care as these infants await surgery or are evaluated for further potential interventions. The newborn with heart disease can present with significant pathophysiologic heterogeneity and therefore requires a personalized therapeutic management plan. However, this complex field of neonatal–cardiac hemodynamics can be simplified. We explore some of these clinical quandaries and include specific sections reviewing the anatomic challenges in these patients. We propose this to serve as a primer focusing on the hemodynamics and therapeutic strategies for the preoperative neonate with systolic dysfunction, diastolic dysfunction, excessive pulmonary blood flow, obstructed pulmonary blood flow, obstructed systemic blood flow, transposition physiology, and single ventricle physiology.
Introduction: Advances in pediatric heart failure (HF) therapies have resulted in improved surviv... more Introduction: Advances in pediatric heart failure (HF) therapies have resulted in improved survival and a resultant shift toward improving long-term quality of life. Aim of this study was to determ...
Background: Hypertrophic cardiomyopathy (HCM) is a common disease with heterogeneous clinical pre... more Background: Hypertrophic cardiomyopathy (HCM) is a common disease with heterogeneous clinical presentation and risk of sudden cardiac death. In pediatrics, HCM is the most common cause of sudden ca...
HERD: Health Environments Research & Design Journal, 2021
Background:The intensive care environment in hospitals has been the subject of significant empiri... more Background:The intensive care environment in hospitals has been the subject of significant empirical and qualitative research in the 2005–2020 period. Particular attention has been devoted to the role of infection control, family engagement, staff performance, and the built environment ramifications of the recent COVID-19 global pandemic. A comprehensive review of this literature is reported summarizing recent advancements in this rapidly expanding body of knowledge.Purpose and Aim:This comprehensive review conceptually structures the recent medical intensive care literature to provide conceptual clarity and identify current priorities and future evidence-based research and design priorities.Method and Result:Each source reviewed was classified as one of the five types—opinion pieces/essays, cross-sectional empirical investigations, nonrandomized comparative investigations, randomized studies, and policy review essays—and into nine content categories: nature engagement and outdoor v...
Background Severe illness in children is associated with significant risk of permanent disability... more Background Severe illness in children is associated with significant risk of permanent disability, cardiac arrest, and death. The Severe Illness Getting Noticed Sooner (SIGNS) for Kids was created by an expert panel to help parents and other caregivers identify and articulate signs of severe illness to enable timely escalation of care. SIGNS for Kids consists of 5 major items: Behaviour, Breathing, Skin, Fluids, and Response to usually effective treatments. Expert development ensured face validity, however there is no formal validity evidence to suggest the tool can identify children with severe illness. Objectives To provide preliminary validity evidence of the sensitivity of the SIGNS criteria as markers of severe illness. Design/Methods A retrospective review of paediatric deaths was performed using records from the coroner’s office. Eligible patients had an index event described and were <18 years and >36 weeks gestational age at the time of event, had observations/reports...
Background: Discussions continue as to whether ventricular septal defects are best categorized ac... more Background: Discussions continue as to whether ventricular septal defects are best categorized according to their right ventricular geography or their borders. This is especially true when considering the perimembranous defect. Our aim, therefore, was to establish the phenotypic feature of the perimembranous defect, and to establish the ease of distinguishing its geographical variants. Methods and results: We assessed unrepaired isolated perimembranous ventricular defects from six historic archives, subcategorizing them using the ICD-11 coding system. We identified 365 defects, of which 94 (26%) were deemed to open centrally, 168 (46%) to open to the outlet, and 84 (23%) to the inlet of the right ventricle, with 19 (5%) being confluent. In all hearts, the unifying phenotypic feature was fibrous continuity between the leaflets of the mitral and tricuspid valves. This was often directly between the valves, but in all instances incorporated continuity through the atrioventricular portion of the membranous septum. In contrast, we observed fibrous continuity between the leaflets of the tricuspid and aortic valves in only 298 (82%) of the specimens. When found, discontinuity most commonly was seen in the outlet and central defects. There were no discrepancies between evaluators in distinguishing the borders, but there was occasional disagreement in determining the right ventricular geography of the defect. Conclusions: The unifying feature of perimembranous defects, rather than being aortic-to-tricuspid valvar fibrous continuity, is fibrous continuity between the leaflets of the atrioventricular valves. While right ventricular geography is important in classification, it is the borders which are more objectively defined.
Cardiology fellows-in-training, both in adult and pediatric hospitals, need structured education ... more Cardiology fellows-in-training, both in adult and pediatric hospitals, need structured education in regards to congenital heart disease (CHD) nomenclature. With improved survival of patients with CHD, it is not uncommon for these patients to seek care in multiple adult and pediatric hospitals. A deep understanding of CHD nomenclature would aid in providing accurate medical and surgical care for these patients. In this forum, we share our experience with such structured education and also comment on recent advances in morphologic imaging that would aid in understanding the nomenclature.
A 14-year-old previously healthy, fully immunized white male presented to an urgent care with 1 d... more A 14-year-old previously healthy, fully immunized white male presented to an urgent care with 1 day of right facial swelling with erythema and emesis. He was diagnosed with parotitis, given 1 dose of intramuscular ceftriaxone and started on amoxicillin/clavulanic acid. His symptoms worsened over the next 2 days to include an intermittent, diffuse pruritic rash and high fevers (Tmax 106.6°F). He returned to the urgent care and was subsequently referred to a tertiary care center emergency department and admitted due to ill appearance and inability to tolerate oral intake. The admission physical examination revealed an illappearing male with diffuse erythematous maculopapular rash involving palms and soles, marked right parotid swelling, and bilateral upper quadrant abdominal tenderness without hepatosplenomegaly. Initial laboratory analysis was remarkable for hyponatremia (130 mmol/L), hypochloremia (96 mmol/L), transaminitis (alanine transaminase [ALT] 316 mmol/L, aspartate transaminase [AST] 248 mmol/L), direct hyperbilirubinemia (total bilirubin 2.9 mg/dL, direct bilirubin 1.6 mg/dL) and normal complete blood count. He was started on intravenous nafcillin for suspected bacterial parotitis. Further history elucidated a recent trip to West Virginia; therefore, doxycycline was added to include coverage for tick-borne illnesses.
TRIM5 proteins mediate a potent block to the cross-species transmission of retroviruses, the most... more TRIM5 proteins mediate a potent block to the cross-species transmission of retroviruses, the most well known being the TRIM5α protein from rhesus macaques, which potently inhibits human immunodeficiency virus type 1 (HIV-1) infection. This restriction occurs at an early stage in the replication cycle and is mediated by the binding of TRIM5 proteins to determinants present in the retroviral capsid. TRIM5α, as well as other TRIM family proteins, has been shown to be regulated by interferons (IFN). Here we show that TRIM5α associates with another IFN-induced gene, sequestosome-1/p62 (p62). p62 plays a role in several signal transduction cascades that are important for maintaining the antiviral state of cells. Here we demonstrate that p62 localizes to both human and rhesus macaque TRIM5α cytoplasmic bodies, and fluorescence resonance energy transfer (FRET) analysis demonstrates that these proteins closely associate in these structures. When p62 expression was knocked down via small inte...
Pulmonary and systemic vascular responses to ketamine (2 mg. kg-', intravenously) were studied du... more Pulmonary and systemic vascular responses to ketamine (2 mg. kg-', intravenously) were studied during cardiac catheterization in 20 children with congenital heart lesions. Pulmonary and systemic resistances (Rp, Rs), ratios between pulmonary and systemic flows (QplQs), and left to right (L + R) and right to left shunts (R + L) were calculated before and after ketamine administration. Statistically significant (P < 0.05) but clinically minor increases in heart rate (106.8 to 109.9 beatslmiid, mean pulmonary artery pressure (20.6 to 22.8 mm Hg), and RpiRs (0.12 to 0.14j were seen after ketamine. There were no significant changes in systemic arterial pressure, Rs, QpiQs, L + R, R-+ L, or arterial oxygen or carbon dioxide tensions. No patient had any major untoward effects from ketamine administration. It is concluded that the hemodynarnic alterations after ketamine administration in children undergoing cardiac catheterization are small and do not alter the clinical status of the patients or the information obtained by cardiac catheterization.
Objective: To optimize patient resource utilization and safety, we created a standard-of-care gui... more Objective: To optimize patient resource utilization and safety, we created a standard-of-care guideline for pediatric drug ingestion hospital admissions. Methods: A multidisciplinary committee developed specific telemetry guidelines for pediatric drug ingestion hospital admissions at a tertiary pediatric hospital. The guidelines stipulated inpatient admission with telemetry monitoring for the following criteria: (1) corrected QT interval (interval between the Q wave and T wave on a standard EKG)≥ 500 ms, (2) ingestion of an antiarrhythmic medication, or (3) ingestion of a tricyclic antidepressant. We created guidelines for electrocardiogram frequency for nontelemetry admissions. We implemented these guidelines in November 2015 in partnership with the Emergency Medicine Department and Poison Control Center. We reviewed medical records of all these admissions between
Introduction and Objective Enteral nutrition (EN) is often withheld from neonates with congenital... more Introduction and Objective Enteral nutrition (EN) is often withheld from neonates with congenital heart disease due to concerns of necrotizing enterocolitis (NEC), despite limited evidence showing no association between the two in this population. This study sought to confirm the association between EN and NEC and determine if this relationship was influenced by feeding practices. Methods This single-center retrospective study included all neonates with congenital heart disease admitted to the Cardiac Critical Care Unit (CCCU) at the Hospital for Sick Children, Toronto between July 1, 2016 and …
Children with congenital heart disease (CHD) are prone to nutritional challenges and undernutriti... more Children with congenital heart disease (CHD) are prone to nutritional challenges and undernutrition. For children with unrepaired CHD, growth is often compromised due to caloric imbalance stemming from high energy expenditure and poor nutritional intake as a result of feeding intolerance, fluid restriction, and impaired absorption. The resulting undernutrition is associated with frequent infections, poor wound healing, and increased mortality, creating strong incentives for early and aggressive nutrition intervention. Management strategies are therefore aimed at ensuring that dietary provisions meet the child's distinctive needs by prioritising human milk for infants, increasing energy delivery through higher caloric density feeds, use of enteral feeding tubes, parenteral nutrition for energy supplementation, and medical therapy to treat feeding intolerance. The perioperative period also presents unique challenges and opportunities for nutritional support, including early introduction of enteral nutrition to support improved postoperative recovery and ensuring feeding delivery meets the child's energy and protein requirements to avoid a catabolic state. Indirect calorimetry can be utilized to measure energy consumption and avoid under or over nutrition. Specific nutritional approaches affecting the CHD population are also required, such as chylothorax or protein-losing enteropathy, to provide adequate nutritional support without contributing to harm. This narrative review describes the nutritional considerations, obstacles and complications faced by children with CHD across their different phases of care, and the treatment approaches aimed to mitigate a negative impact.
Objectives An eight-bed adult coronavirus (COVID-19) critical care (CC) unit was established with... more Objectives An eight-bed adult coronavirus (COVID-19) critical care (CC) unit was established within our pediatric CC unit (PCCU) when SARS-CoV-2 (severe acute respiratory syndrome coronavirus 2) variants increased the CC bed demand. Our objective was to rapidly implement electronic order sets (OSs) to facilitate computerized provider order entry (CPOE) for adult patients admitted within a children's hospital. Methods OS development began from the assessment of OSs from seven adult CC units. Using a pre-existing PCCU admission template, we created two OSs: adult COVID-19 admission and ongoing care. We tested the prototypes in a multidisciplinary onsite–virtual hybrid tabletop simulation to evaluate usability within established workflows. Participants utilized role-specific profiles within the electronic health record (EHR) training environment which paralleled their computer interface, permitting charting and documentation. EHR analysts were present to gather change requests. Fol...
Clinicians caring for neonates with congenital heart disease encounter challenges in clinical car... more Clinicians caring for neonates with congenital heart disease encounter challenges in clinical care as these infants await surgery or are evaluated for further potential interventions. The newborn with heart disease can present with significant pathophysiologic heterogeneity and therefore requires a personalized therapeutic management plan. However, this complex field of neonatal–cardiac hemodynamics can be simplified. We explore some of these clinical quandaries and include specific sections reviewing the anatomic challenges in these patients. We propose this to serve as a primer focusing on the hemodynamics and therapeutic strategies for the preoperative neonate with systolic dysfunction, diastolic dysfunction, excessive pulmonary blood flow, obstructed pulmonary blood flow, obstructed systemic blood flow, transposition physiology, and single ventricle physiology.
Introduction: Advances in pediatric heart failure (HF) therapies have resulted in improved surviv... more Introduction: Advances in pediatric heart failure (HF) therapies have resulted in improved survival and a resultant shift toward improving long-term quality of life. Aim of this study was to determ...
Background: Hypertrophic cardiomyopathy (HCM) is a common disease with heterogeneous clinical pre... more Background: Hypertrophic cardiomyopathy (HCM) is a common disease with heterogeneous clinical presentation and risk of sudden cardiac death. In pediatrics, HCM is the most common cause of sudden ca...
HERD: Health Environments Research & Design Journal, 2021
Background:The intensive care environment in hospitals has been the subject of significant empiri... more Background:The intensive care environment in hospitals has been the subject of significant empirical and qualitative research in the 2005–2020 period. Particular attention has been devoted to the role of infection control, family engagement, staff performance, and the built environment ramifications of the recent COVID-19 global pandemic. A comprehensive review of this literature is reported summarizing recent advancements in this rapidly expanding body of knowledge.Purpose and Aim:This comprehensive review conceptually structures the recent medical intensive care literature to provide conceptual clarity and identify current priorities and future evidence-based research and design priorities.Method and Result:Each source reviewed was classified as one of the five types—opinion pieces/essays, cross-sectional empirical investigations, nonrandomized comparative investigations, randomized studies, and policy review essays—and into nine content categories: nature engagement and outdoor v...
Background Severe illness in children is associated with significant risk of permanent disability... more Background Severe illness in children is associated with significant risk of permanent disability, cardiac arrest, and death. The Severe Illness Getting Noticed Sooner (SIGNS) for Kids was created by an expert panel to help parents and other caregivers identify and articulate signs of severe illness to enable timely escalation of care. SIGNS for Kids consists of 5 major items: Behaviour, Breathing, Skin, Fluids, and Response to usually effective treatments. Expert development ensured face validity, however there is no formal validity evidence to suggest the tool can identify children with severe illness. Objectives To provide preliminary validity evidence of the sensitivity of the SIGNS criteria as markers of severe illness. Design/Methods A retrospective review of paediatric deaths was performed using records from the coroner’s office. Eligible patients had an index event described and were <18 years and >36 weeks gestational age at the time of event, had observations/reports...
Background: Discussions continue as to whether ventricular septal defects are best categorized ac... more Background: Discussions continue as to whether ventricular septal defects are best categorized according to their right ventricular geography or their borders. This is especially true when considering the perimembranous defect. Our aim, therefore, was to establish the phenotypic feature of the perimembranous defect, and to establish the ease of distinguishing its geographical variants. Methods and results: We assessed unrepaired isolated perimembranous ventricular defects from six historic archives, subcategorizing them using the ICD-11 coding system. We identified 365 defects, of which 94 (26%) were deemed to open centrally, 168 (46%) to open to the outlet, and 84 (23%) to the inlet of the right ventricle, with 19 (5%) being confluent. In all hearts, the unifying phenotypic feature was fibrous continuity between the leaflets of the mitral and tricuspid valves. This was often directly between the valves, but in all instances incorporated continuity through the atrioventricular portion of the membranous septum. In contrast, we observed fibrous continuity between the leaflets of the tricuspid and aortic valves in only 298 (82%) of the specimens. When found, discontinuity most commonly was seen in the outlet and central defects. There were no discrepancies between evaluators in distinguishing the borders, but there was occasional disagreement in determining the right ventricular geography of the defect. Conclusions: The unifying feature of perimembranous defects, rather than being aortic-to-tricuspid valvar fibrous continuity, is fibrous continuity between the leaflets of the atrioventricular valves. While right ventricular geography is important in classification, it is the borders which are more objectively defined.
Cardiology fellows-in-training, both in adult and pediatric hospitals, need structured education ... more Cardiology fellows-in-training, both in adult and pediatric hospitals, need structured education in regards to congenital heart disease (CHD) nomenclature. With improved survival of patients with CHD, it is not uncommon for these patients to seek care in multiple adult and pediatric hospitals. A deep understanding of CHD nomenclature would aid in providing accurate medical and surgical care for these patients. In this forum, we share our experience with such structured education and also comment on recent advances in morphologic imaging that would aid in understanding the nomenclature.
A 14-year-old previously healthy, fully immunized white male presented to an urgent care with 1 d... more A 14-year-old previously healthy, fully immunized white male presented to an urgent care with 1 day of right facial swelling with erythema and emesis. He was diagnosed with parotitis, given 1 dose of intramuscular ceftriaxone and started on amoxicillin/clavulanic acid. His symptoms worsened over the next 2 days to include an intermittent, diffuse pruritic rash and high fevers (Tmax 106.6°F). He returned to the urgent care and was subsequently referred to a tertiary care center emergency department and admitted due to ill appearance and inability to tolerate oral intake. The admission physical examination revealed an illappearing male with diffuse erythematous maculopapular rash involving palms and soles, marked right parotid swelling, and bilateral upper quadrant abdominal tenderness without hepatosplenomegaly. Initial laboratory analysis was remarkable for hyponatremia (130 mmol/L), hypochloremia (96 mmol/L), transaminitis (alanine transaminase [ALT] 316 mmol/L, aspartate transaminase [AST] 248 mmol/L), direct hyperbilirubinemia (total bilirubin 2.9 mg/dL, direct bilirubin 1.6 mg/dL) and normal complete blood count. He was started on intravenous nafcillin for suspected bacterial parotitis. Further history elucidated a recent trip to West Virginia; therefore, doxycycline was added to include coverage for tick-borne illnesses.
TRIM5 proteins mediate a potent block to the cross-species transmission of retroviruses, the most... more TRIM5 proteins mediate a potent block to the cross-species transmission of retroviruses, the most well known being the TRIM5α protein from rhesus macaques, which potently inhibits human immunodeficiency virus type 1 (HIV-1) infection. This restriction occurs at an early stage in the replication cycle and is mediated by the binding of TRIM5 proteins to determinants present in the retroviral capsid. TRIM5α, as well as other TRIM family proteins, has been shown to be regulated by interferons (IFN). Here we show that TRIM5α associates with another IFN-induced gene, sequestosome-1/p62 (p62). p62 plays a role in several signal transduction cascades that are important for maintaining the antiviral state of cells. Here we demonstrate that p62 localizes to both human and rhesus macaque TRIM5α cytoplasmic bodies, and fluorescence resonance energy transfer (FRET) analysis demonstrates that these proteins closely associate in these structures. When p62 expression was knocked down via small inte...
Pulmonary and systemic vascular responses to ketamine (2 mg. kg-', intravenously) were studied du... more Pulmonary and systemic vascular responses to ketamine (2 mg. kg-', intravenously) were studied during cardiac catheterization in 20 children with congenital heart lesions. Pulmonary and systemic resistances (Rp, Rs), ratios between pulmonary and systemic flows (QplQs), and left to right (L + R) and right to left shunts (R + L) were calculated before and after ketamine administration. Statistically significant (P < 0.05) but clinically minor increases in heart rate (106.8 to 109.9 beatslmiid, mean pulmonary artery pressure (20.6 to 22.8 mm Hg), and RpiRs (0.12 to 0.14j were seen after ketamine. There were no significant changes in systemic arterial pressure, Rs, QpiQs, L + R, R-+ L, or arterial oxygen or carbon dioxide tensions. No patient had any major untoward effects from ketamine administration. It is concluded that the hemodynarnic alterations after ketamine administration in children undergoing cardiac catheterization are small and do not alter the clinical status of the patients or the information obtained by cardiac catheterization.
Objective: To optimize patient resource utilization and safety, we created a standard-of-care gui... more Objective: To optimize patient resource utilization and safety, we created a standard-of-care guideline for pediatric drug ingestion hospital admissions. Methods: A multidisciplinary committee developed specific telemetry guidelines for pediatric drug ingestion hospital admissions at a tertiary pediatric hospital. The guidelines stipulated inpatient admission with telemetry monitoring for the following criteria: (1) corrected QT interval (interval between the Q wave and T wave on a standard EKG)≥ 500 ms, (2) ingestion of an antiarrhythmic medication, or (3) ingestion of a tricyclic antidepressant. We created guidelines for electrocardiogram frequency for nontelemetry admissions. We implemented these guidelines in November 2015 in partnership with the Emergency Medicine Department and Poison Control Center. We reviewed medical records of all these admissions between
Introduction and Objective Enteral nutrition (EN) is often withheld from neonates with congenital... more Introduction and Objective Enteral nutrition (EN) is often withheld from neonates with congenital heart disease due to concerns of necrotizing enterocolitis (NEC), despite limited evidence showing no association between the two in this population. This study sought to confirm the association between EN and NEC and determine if this relationship was influenced by feeding practices. Methods This single-center retrospective study included all neonates with congenital heart disease admitted to the Cardiac Critical Care Unit (CCCU) at the Hospital for Sick Children, Toronto between July 1, 2016 and …
Children with congenital heart disease (CHD) are prone to nutritional challenges and undernutriti... more Children with congenital heart disease (CHD) are prone to nutritional challenges and undernutrition. For children with unrepaired CHD, growth is often compromised due to caloric imbalance stemming from high energy expenditure and poor nutritional intake as a result of feeding intolerance, fluid restriction, and impaired absorption. The resulting undernutrition is associated with frequent infections, poor wound healing, and increased mortality, creating strong incentives for early and aggressive nutrition intervention. Management strategies are therefore aimed at ensuring that dietary provisions meet the child's distinctive needs by prioritising human milk for infants, increasing energy delivery through higher caloric density feeds, use of enteral feeding tubes, parenteral nutrition for energy supplementation, and medical therapy to treat feeding intolerance. The perioperative period also presents unique challenges and opportunities for nutritional support, including early introduction of enteral nutrition to support improved postoperative recovery and ensuring feeding delivery meets the child's energy and protein requirements to avoid a catabolic state. Indirect calorimetry can be utilized to measure energy consumption and avoid under or over nutrition. Specific nutritional approaches affecting the CHD population are also required, such as chylothorax or protein-losing enteropathy, to provide adequate nutritional support without contributing to harm. This narrative review describes the nutritional considerations, obstacles and complications faced by children with CHD across their different phases of care, and the treatment approaches aimed to mitigate a negative impact.
Uploads
Papers by Seth Gray