Age and sex-related comparison of referral-based telemedicine service utilization during the COVID-19 pandemic in Ontario: a retrospective analysis.

BACKGROUND: The COVID-19 pandemic has led to increased utilization of telemedicine services. METHODS: A retrospective analysis of all referral-based ambulatory telemedicine services in Ontario from November 2019 to June 2021 was collected from the Ontario Health Insurance Plan (OHIP) billing database. Only fee-for-service billings were included in the present analysis. Coincident COVID-19 cases were obtained from Public Health Ontario. Comparisons were made based on age bracket, sex, telemedicine and in-person care. RESULTS: Billings for telemedicine services in Ontario increased from $1.7 million CAD in November 2019 to $64 million CAD in April 2020 and the proportions reached a mean peak of 72% in April 2020 and declined to 46% in June 2021. A positive correlation was found between the use of telemedicine and COVID-19 cases (p = 0.05). The age group with the highest proportion of telemedicine use was the 10-20-year-olds, followed by the 20-50-year-olds (61 ± 9.0%, 55 ± 7.3%, p = 0.01). Both age groups remained above 50% telemedicine services at the end of the study period. There seemed to be higher utilization by females (females 54.2 ± 8.0%, males 47.9 ± 7.7%, ANCOVA p = 0.05) for all specialties, however, after adjusting for male to female ratio m:f of 0.952:1.0 according to the 2016 census, this was no longer significant. CONCLUSIONS: The use of telemedicine services remained at a high level across groups, particularly the 10-50-year-olds. There were clear age preferences for using telemedicine. Studying these differences may provide insights into how the delivery of non-hospital-based medicine has changed during the COVID-19 pandemic.

Innovative online care: A cross-sectional survey study of potential benefits and challenges of online lactation consultation service with paediatrician consultation.

Background: Telelactation, a virtual lactation support platform, is a convenient and effective way of providing virtual breastfeeding support services and communicating proper breastfeeding techniques to new mothers to address any breastfeeding challenges and boost overall maternal breastfeeding confidence all from the comfort of their homes. This Ontario Health Insurance Plan (OHIP) covered service benefits more mothers in the remote areas where in-person LC service is not easily accessible. Objective: The objective of this cross-sectional survey study is to explore the feasibility, potential benefits, and challenges, and level of patient satisfaction in virtual lactation consultation services along with virtual paediatrician consultation available in Ontario, Canada. Method: Patient satisfaction was assessed using a structured online survey as a part of a cross-sectional observational study that asked questions relevant to several independent demographic variables as well as specific Likert type scale questions to gauge patient satisfaction with virtual lactation consultation. Results: Data were analyzed from 177 survey responses (n=177), of which study revealed that 86.44% (153/177) were satisfied with the virtual lactation services they received. Patient satisfaction was found to be higher in the first-time mothers with high school or undergraduate education between the age group of 26 to 35 years living in the Greater Toronto Area (GTA). In terms of connectivity, participants from the GTA had a better experience overall compared those living outside the GTA. Conclusion: OHIP covered telelactation with a paediatrician consultation is an innovative and feasible health care delivery platform for providing remote professional breastfeeding support to mothers of all socio-economic strata with great potential to further improve both patient experience and efficiency in patient care.

Recreational Cannabis Legalization in Canada: A Pediatrics Perspective.

Background: Despite its controversial nature, the use of recreational marijuana and cannabis-derived products continue to increase in popularity. Cannabis consumption is currently legal in certain American states as well as Canada, and it is also frequently used by Canadian youth. However, cannabis use during childhood and adolescence can contribute to significant harm. Materials andMethods: A review of current literature regarding the impacts of cannabis consumption among Canadian youth was conducted. Medline, Cochrane, Embase and PubMed databases were utilized to identify journal articles published within 10 years that highlighted the impacts of cannabis consumption in its different forms among the North American pediatric population. Results: Our review identified harms include structural and functional impairments in the developing brain, the development of mental health conditions such as depression and anxiety, impaired road safety while driving under the influence of cannabis, and the significant consequences of accidental ingestion of cannabis products by children. We also ascertained that cannabis cessation strategies that employed an affective model, which explores the root causes of adolescents turning to cannabis, are most effective in reducing substance use among adolescents. Conclusions: In light of the recent legalization of cannabis in Canada, the purpose of this article was to provide background on cannabis consumption and its legalization in Canada, the impacts of cannabis on Canadian youth, and evidence-based strategies to help mitigate them.

Utility of Clinical and Ultrasonographic Hip Screening in Neonates for Developmental Dysplasia of the Hip.

Developmental dysplasia of the hip (DDH) is a musculoskeletal condition occupying any point along a spectrum of anatomical abnormalities that alter the stability of the newborn hip. Presentation varies throughout infancy and the majority of cases, especially those that are mild in nature, tend to resolve without intervention. An analysis of outcomes was conducted on infants born over a two-year period at a single-center, community hospital in East Toronto. The unwritten norm at the institution has become to order hip ultrasonography for all infants born in the breech position through C-section. Given the healthcare expenditure associated with routine radiographic screening, a careful analysis was undertaken to ascertain whether this screening regimen was effective in preventing late-stage detection of advanced DDH and improving organization in patient management. There were a total of 4236 babies delivered over the two years. One-hundred sixty-four (164) babies were born breech and through C-section. Eight (8) babies had abnormal hip examinations, one of whom was ultimately diagnosed with DDH. Forty-six (46) babies showed abnormal hip ultrasound at six weeks. Seventeen (17) referrals were made to the orthopedic surgeon. This resulted in a total of seven cases of DDH being diagnosed over the two years. The sensitivity and specificity of clinical hip screening were 14.3% and 95.5%, respectively, while that for ultrasound screening was 100% and 75.2%. To improve the quality of care and detection of DDH, a risk factor analysis was conducted to retrospectively analyze which DDH cases would have been missed if a higher threshold to ordering hip ultrasonography had been used. Based on the test characteristics of clinical and ultrasonographic screening, held in conjunction with the risk factor analysis results, an altered screening regimen was proposed with the intention of being just as sensitive but more cost-effective. This regimen integrates clinical screening using Barlow and Ortalani maneuvers until the eight to 10-week period and examines for limited abduction from eight weeks onward. Adjuncts like the Galeazzi test and that for asymmetrical skin folds should also be included to increase the sensitivity of clinical screening. Ultrasonography is proposed for high-risk individuals, with the criteria for stratification as high-risk being extracted from the risk factor analysis. Ultrasound is also proposed to be done in a serial fashion prior to orthopedic surgery referral in cases where the age of the infant allows, which serves to better evaluate the risk for lasting DDH and understand the longitudinal trajectory of the patient. This serves the additional purpose of decreasing the psychosocial burden on families. This can be particularly significant for infants for whom the initial abnormalities are due to self-resolve with the maturation of the hip joint and the infant's growth.

Collecting the golden water: Quality assessment on approach of diagnosing urinary tract infections in 0 to 36 months old children.

OBJECTIVE: The study aimed to assess current practices of a community hospital for collection of urine sample when diagnosis of urinary tract infection (UTI) is suspected in children aged 0 to 36 months old. METHODS: An analysis of paediatric patients aged 0 to 36 months old was performed in two separate audits to assess the quality of urine sampling. The first, retrospective analysis comprised of urine collections techniques in a community hospital for diagnosis of UTI followed by an education intervention in which the hospital staff was briefed regarding the Canadian Paediatric Society (CPS) position statement for diagnosis and management of UTI. CPS recommendations were transposed using PowerPoint presentations, reminders at unit huddles, and other educational forums. Second audit was a prospective analysis which was conducted 6 months after the educations intervention. RESULTS: Bagged sampling had higher sensitivity and lower specificity due to sample contamination, versus transurethral bladder catheterization and suprapubic aspiration. The first audit showed that while 66% of culture-positive urine sampling was performed via the bagging, only 26% those positive cultures were repeated before treatment. In the second audit, after educational intervention, 33% of culture-positive urine collection was done via the bagging method and repeat testing was done in 83% of positive results on a bagged sample before initiating treatment. The false-positive rate for the diagnosis of UTIs in the first and second audit was 65.7 and 60%, respectively. CONCLUSION: Our study recognizes the flaws in community hospital practices in the diagnosis of UTI in children and validates the significance of educational intervention in improving health care.

United States County-level COVID-19 Death Rates and Case Fatality Rates Vary by Region and Urban Status.

COVID-19 is a global pandemic with uncertain death rates. We examined county-level population morality rates (per 100,000) and case fatality rates by US region and rural-urban classification, while controlling for demographic, socioeconomic, and hospital variables. We found that population mortality rates and case fatality rates were significantly different across region, rural-urban classification, and their interaction. All significant comparisons had p < 0.001. Northeast counties had the highest population mortality rates (27.4) but had similar case fatality rates (5.9%) compared to other regions except the Southeast, which had significantly lower rates (4.1%). Population mortality rates were highest in urban counties but conversely, case fatality rates were highest in rural counties. Death rates in the Northeast were driven by urban areas (e.g., small, East Coast states), while case fatality rates tended to be highest in the most rural counties for all regions, especially the Southwest. However, on further inspection, high case fatality rate percentages in the Southwest, as well as in overall US counties, were driven by a low case number. This makes it hard to distinguish genuinely higher mortality or an artifact of a small sample size. In summary, coronavirus deaths are not homogenous across the United States but instead vary by region and population and highlight the importance of fine-scale analysis.

The importance of visualization of appendix on abdominal ultrasound for the diagnosis of appendicitis in children: A quality assessment review.

BACKGROUND: Ultrasound has the first line investigation role in the diagnosis of acute appendicitis in children. The purpose of this study was to perform a quality assessment review on the visualization rate of appendix on ultrasound in children in the community hospital setting. METHODS: A retrospective chart review of the abdominal ultrasound findings for the visualization of the appendix was performed on paediatric patients ranging from 5 to 18 years. Data were collected from the two community hospitals of Toronto by using hospital electronic medical record for the ultrasound findings in patients presented with abdominal pain. RESULTS: Data from two community hospitals indicated visualization rate of the appendix as 11.0% and 23.2% for site 1 and site 2 respectively. In cases where the ultrasound was repeated the visualization rate remains the same. A two-proportion z-test was performed to find whether the visualization of appendix increases the likelihood of diagnosing appendicitis. The results revealed that the visualization of an appendix (P=0.52), significantly improved the diagnosis of appendicitis (z=34, P<0.001). CONCLUSION: Visualization of an appendix on ultrasound increases the likelihood of correctly diagnosing appendicitis. In our study, we found low visualization rate of appendix on ultrasound that could be the result of many factors that contribute towards the low visualization rate of an appendix on ultrasound. Hence, the challenges in identifying appendix should be minimized to improve the visualization and diagnosis of appendicitis on ultrasound.

Paediatric-appropriate facilities in emergency departments of community hospitals in Ontario: A cross-sectional study.

BACKGROUND: We assessed whether the paediatric-appropriate facilities were available at Emergency Departments (ED) in community hospitals in a Canadian province. METHODS: We conducted a cross-sectional survey of EDs in community hospitals in Ontario, Canada that had inpatient paediatric facilities and a neonatal intensive care unit. Key informants were ED chiefs, clinical educators, or managers. The survey included questions about paediatric facilities related to environment, triage, training, and staff in EDs. RESULTS: Of 52 hospitals, 69% (n=36) responded to our survey. Of them, 14% EDs (n=5) had some separated spaces available for paediatric patients. About 53% (n=19) of EDs lacked children activities, e.g., toys. Only 11% (n=4) EDs were using paediatric triage scales and 42% (n=15) had a designated paediatric resuscitation bay. Only half of the ED (n=18) required from their staff to update paediatric life support training. Only 31% (n=11) had a designated liaison paediatrician for the ED. Paediatric social worker was present in only 8% (n=3) of EDs in community hospitals. CONCLUSION: Most of the Ontario community hospital EDs included in this survey had inadequate facilities for paediatric patients such as specific waiting and treatment areas.

Pulse oximetry: A reliable and cost effective screening tool in children with pneumonia for developing countries.

The infant mortality rates are high in developing countries and, according to World Health Organisation (WHO), statistics show that the main contributors are acute respiratory infections and pneumonia. In children hypoxaemia is an ominous sign associated with respiratory tract infections. Hypoxia can be detected easily with pulse oximetry. It is a non-invasive, readily available and cost-effective way to identify hypoxaemia. If we identify hypoxaemia at the primary care level, especially in a low-income setting, we can make early referral to tertiary care settings. This will subsequently have a positive impact in saving lives. A detailed search of Medline database was conducted through PubMed from 1990 to date, to review the literature on the usefulness of pulse oximetry at primary care centres in developing countries. Such information will become vital in formulating guidelines for income-poor countries in order to stratify high-risk children with hypoxaemia.