Short-course systemic corticosteroids (SCS) are recommended for moderate-to-severe pediatric asthma exacerbations, though frequent courses may cause adverse outcomes. We examined the risk of adverse outcomes in asthmatic children who received multiple SCS courses for exacerbation management. We conducted a retrospective study of children aged 1–16 years with an asthma emergency department presentation/hospitalization between October 1, 2017, and February 28, 2021. Using a Prentice-Williams-Peterson total time model, we compared steroid-associated adverse outcomes among children who received or did not receive short courses of SCS for asthma exacerbations over ≥ 24-months. Among 2009 eligible children, 1468 received ≥ 1 SCS course for asthma exacerbations and 541 did not receive SCS. Overall, there was no increase in the risk of recurrent SCS-associated adverse outcomes in those exposed to SCS (aHR = 0.95, 95

OBJECTIVE:Large population-based asthma registries improve disease understanding and management and can be developed through the secondary use of electronic medical records (EMRs). We have created an Epic-EMR registry of children treated for asthma at the Children's Hospital of Eastern Ontario (CHEO). This study's objective was to validate the Epic-EMR asthma registry by comparing it against expert clinical asthma diagnoses. METHODS:The sample included children aged 0-18 years. We randomly selected 200 children from the Epic-EMR asthma registry, 200 children with non-asthma respiratory conditions, and 200 children with non-asthma, non-respiratory diagnoses. All asthma diagnoses were verified by two blinded pediatric respirologists based on data abstracted from the electronic chart. RESULTS:In total 598 children were included for analysis. The Epic-EMR asthma registry had a positive predictive value of 0.91 (95%CI 0.86-0.94) and negative predictive value of 0.92 (95%CI 0.89-0.94). Correcting for the proportion of CHEO patients in the asthma registry (6.6%), the estimated specificity was 0.99 (95%CI 0.99-0.99) and sensitivity was 0.44 (95%CI 0.36-0.53). When age-stratified, the specificity was 0.99 (95%CI 0.99-0.99) and sensitivity was 0.39 (95%CI 0.29-0.50) for participants aged 0 to <6 years, and 0.99 (95%CI 0.98-0.99) and 0.5 (95%CI 0.37-0.63) for participants aged 6-18 years. CONCLUSION:The Epic-EMR asthma registry accurately identifies children with asthma. With a very high specificity, positive and negative predictive value, this tool is appropriate to use for clinical care and research.

BACKGROUND:Vitamin D supplementation may improve asthma by modulating inflammation, but its effects in preschoolers with virus-induced asthma remain underexplored. OBJECTIVE:To measure the association between serum 25-hydroxyvitamin D (25(OH)D) and inflammatory biomarkers and the impact of vitamin D supplementation on these biomarkers. METHODS:We conducted a nested study within a 7-month randomized placebo-controlled trial. Children aged 1 to 5 years with virus-induced asthma received vitamin D3 in 2 oral boluses (100,000 IU) 3.5 months apart, with a daily (400 IU) supplement, or placebo boluses and daily supplement. Serum 25(OH)D and C-reactive protein (CRP) were measured at baseline, 3.5 months, and 7 months, whereas blood cells were measured at baseline and 7 months. Primary outcomes were CRP across time points and change from baseline in CRP at 3.5 and 7 months, analyzed using generalized estimating equation and mixed-effects models. RESULTS:Among 236 (118 Vitamin D: 118 placebo) children (64.4% male), no significant association was observed between CRP and 25(OH)D. However, neutrophils were inversely associated with 25(OH)D (adjusted β [95% CI]= -0.016 (-0.027 to -0.005) × 10⁹ cells/L, n = 198). Compared with placebo, vitamin D supplementation led to a greater reduction from baseline in CRP over time (adjusted β [95% CI] = -3.154 [-5.978 to -0.330] mg/L, n = 174), and neutrophils at 7 months (adjusted β [95% CI] = -0.657 [-1.288 to -0.026] × 10⁹ cells/L, n = 110). No associations were observed with other blood cell biomarkers. CONCLUSION:In preschoolers with virus-induced asthma, serum 25(OH)D was inversely associated with neutrophils, and vitamin D supplementation significantly reduced CRP and neutrophils over time, suggesting modulation of neutrophilic inflammation. TRIAL REGISTRATION:ClinicalTrials.gov Identifier: NCT03365687.

Obstructive sleep apnea (OSA) affects approximately 5% of children and requires polysomnography (PSG) for diagnosis. As such, population-based longitudinal studies of OSA in children are scarce. We aimed to validate pediatric case definitions of OSA using provincial health administrative datasets and establish a methodology for future longitudinal studies in this population. We performed a multicenter validation study, linking Ontario health administrative data with clinical data for children aged 0-18 years who underwent PSG between 2009-2016 at two tertiary care children's hospitals. We used various administrative case definitions to identify those with the highest sensitivity, specificity, positive and negative likelihood ratios for capturing children with moderate-severe OSA (apnea-hypopnea index ≥5), stratified by age groups (<10 and age ≥ 10 years). The reference cohort included 1,254 children who underwent PSG, with 317 moderate-severe OSA. The overall mean age was 7.7 ± 4.8 years, with 64.8% < 10 years of age and 44% female. The best-performing case definitions included combinations of PSG and adenotonsillectomy or initiation of positive airway pressure therapy within 0-18 months post PSG, or PSG and a diagnostic code for OSA within 6 months pre and 0-18 months post PSG. In children <10 years, these definitions exhibited high specificity (0.80-0.88), with moderate sensitivity (0.62-0.79), positive (3.82-5.25) and negative likelihood ratios (0.27-0.43). However, the performance in children ≥10 was less robust with high specificity (0.85-0.92), moderate positive likelihood ratios (3.48-4.19) and low sensitivity (0.28-0.59), and negative likelihood ratios (0.48-0.78). We have identified case definitions within Ontario health administrative data that have good specificity, and moderate sensitivity, positive and negative likelihood ratios for identifying moderate-severe OSA in children <10 years of age. These can be used in future studies to understand the natural history, predictors and outcomes of young children with OSA, while refined case definitions may still be needed for children ≥10.

Recurrent acute care visits are a common yet preventable outcome for many children with asthma. Machine learning (ML) applied to electronic medical records (EMR) may help identify children at high risk and enable targeted referral to preventative care. We developed ML models to predict repeat asthma-related emergency department (ED) visits or hospital admissions within one year among children with a prior asthma ED visit at a tertiary children's hospital. Retrospective pre-COVID-19 data (Feb 2017-Feb 2019, N = 2716) from the Children's Hospital of Eastern Ontario (CHEO) were linked with environmental pollutant exposure and neighborhood marginalization data to train models. We evaluated boosted tree methods (LGBM, XGBoost) and three open-source large language models (DistilGPT2, Llama 3.2 1B, Llama-8b-UltraMedical). Models were tuned, calibrated, and validated using a post-COVID-19 dataset (Jul 2022-Apr 2023, N = 1237). Performance was assessed using AUC and F1 scores, with SHAP values identifying key predictors. LGBM performed best (AUC 0.712, F1 0.51), outperforming the current best practice (F1 0.334). Key predictors included prior asthma ED visits, triage acuity, medical complexity, food allergy, prior non-asthma respiratory ED visits, and age. AIRE-KIDS models accurately predict future acute care use and could support ED-based decision-making to improve equitable access to preventative asthma care.

RATIONALESevere asthma affects approximately 5% of children with asthma, but accounts for 50% of direct asthma costs. Several knowledge gaps remain in the diagnosis and management of pediatric severe asthma and few evidence-based studies address these needs. Thus, concerted efforts are needed to identify research priorities, conduct collaborative studies and harmonize clinical care.OBJECTIVESIn April 2025, members of the Canadian Pediatric Severe Asthma Research Network and other stakeholders came together at Pediatric Severe Asthma Stakeholders' Forum in Quebec, Canada, to discuss and identify research topics in pediatric severe asthma.METHODSThe Forum comprised the presentation of results from a patient-/caregiver-completed survey on their research priorities, a testimony from a patient and parent-partner and presentations and discussions around three themes: diagnosis and classification, assessment and monitoring and management.MAIN RESULTSSeveral knowledge gaps and related research priorities were identified, including the need for a definition of severe asthma in preschoolers, a better understanding of the true severe asthma endotypes, a pediatric definition of biologics response and severe asthma remission, harmonization of transition care and more data to guide the choice of biologics and predict efficacy in children. Building a hybrid clinical and research database with harmonized variables and the use of novel tools (eg, lung imaging) in collaborative research endeavors could be used to address these knowledge gaps.CONCLUSIONSThis Forum provided an opportunity for stakeholders to discuss and identify priorities in pediatric severe asthma research in Canada, providing a springboard for collaborative, pan-Canadian research in this field. JUSTIFICATIONL'asthme s & eacute;v & egrave;re touche environ 5 % des enfants asthmatiques, mais repr & eacute;sente 50 % des co & ucirc;ts directs li & eacute;s & agrave; l'asthme. Plusieurs lacunes subsistent dans les connaissances concernant le diagnostic et la prise en charge de l'asthme s & eacute;v & egrave;re p & eacute;diatrique, et peu d'& eacute;tudes fond & eacute;es sur des donn & eacute;es probantes y r & eacute;pondent. Ainsi, des efforts concert & eacute;s sont n & eacute;cessaires pour d & eacute;terminer les priorit & eacute;s de recherche, mener des & eacute;tudes collaboratives et harmoniser les soins cliniques.OBJECTIFSEn avril 2025, les membres du R & eacute;seau canadien de recherche sur l'asthme s & eacute;v & egrave;re p & eacute;diatrique et d'autres intervenants se sont r & eacute;unis dans le cadre du Forum des parties prenantes en asthme s & eacute;v & egrave;re p & eacute;diatrique, tenu au Qu & eacute;bec (Canada), afin de discuter des sujets de recherche en asthme s & eacute;v & egrave;re p & eacute;diatrique et d'en identifier les principaux.M & Eacute;THODESLe Forum comprenait la pr & eacute;sentation des r & eacute;sultats d'une enqu & ecirc;te men & eacute;e aupr & egrave;s des patients et des prestataires de soins sur leurs priorit & eacute;s de recherche, un t & eacute;moignage d'un patient partenaire et d'un parent partenaire, ainsi que des pr & eacute;sentations et des discussions autour de trois th & egrave;mes : le diagnostic et la classification, l'& eacute;valuation et le suivi, et la prise en charge.PRINCIPAUX R & Eacute;SULTATSPlusieurs lacunes dans les connaissances et des priorit & eacute;s de recherche connexes ont & eacute;t & eacute; recens & eacute;es, notamment la n & eacute;cessit & eacute; d'une d & eacute;finition de l'asthme s & eacute;v & egrave;re chez les enfants d'& acirc;ge pr & eacute;scolaire, d'une meilleure compr & eacute;hension des v & eacute;ritables endotypes de l'asthme s & eacute;v & egrave;re, d'une d & eacute;finition p & eacute;diatrique de la r & eacute;ponse aux agents biologiques et de la r & eacute;mission de l'asthme s & eacute;v & egrave;re, de l'harmonisation des soins de transition, ainsi que de donn & eacute;es suppl & eacute;mentaires pour guider le choix des agents biologiques et pr & eacute;dire leur efficacit & eacute; chez les enfants. La cr & eacute;ation d'une base de donn & eacute;es hybride, & agrave; la fois clinique et de recherche, comportant des variables harmonis & eacute;es, ainsi que l'utilisation de nouveaux outils (p. ex. l'imagerie pulmonaire) dans le cadre d'efforts de recherche collaborative, pourraient contribuer & agrave; combler ces lacunes en mati & egrave;re de connaissances.CONCLUSIONSCe forum a permis aux parties prenantes de discuter des priorit & eacute;s en mati & egrave;re de recherche sur l'asthme s & eacute;v & egrave;re p & eacute;diatrique au Canada et de les d & eacute;finir. Il constitue un tremplin pour la recherche collaborative pancanadienne dans ce domaine.

BackgroundAsthma exacerbation is a major cause of emergency department visits in children and adolescents. Most of the existing asthma prediction scores and biomarkers are designed to predict severe exacerbations in the medium to long term. Mobile health (mHealth) is a promising approach for integrating real-time, multimodal data to improve the prediction of asthma exacerbation. Using mHealth can enable the identification of at-risk children and the implementation of timely interventions. ObjectiveThe primary objective of the Mobile Health for Kids With Asthma (MoKA) study is to develop a validated predictive model for imminent asthma exacerbation in children using multimodal data, including participant-reported questionnaires through the RespiSentinel mobile app, augmented with publicly sourced environmental and epidemiological data. Furthermore, we will evaluate the association between the frequency of nocturnal cough measured in real time and asthma control and severe asthma exacerbation, and the acceptability of the RespiSentinel app in asthma self-management. MethodsThis is a prospective cohort study with in-person and remote recruitment at 7 tertiary pediatric centers in Canada. Parents of children aged between 1 and 17 years, as well as children who have experienced at least one wheezing episode or asthma exacerbation during the 12 months before recruitment, will be eligible to participate (estimated number of children: n=2000). The planned duration of study participation is 6 months following the date of enrollment (cohort entry), regardless of the number of asthma exacerbations during the follow-up period. The primary outcome will be asthma exacerbation defined by asthma symptoms requiring systemic corticosteroid use and an urgent care or emergency department visit or hospitalization. The predictive model will be created using questionnaire data on asthma control via the RespiSentinel app as well as by integrating publicly available local daily data on air pollutant levels (National Air Pollution Surveillance Program) and weekly prevalence of respiratory viruses (National Canadian Respiratory Virus Detection Surveillance Program). Nocturnal cough frequency will be determined by using nighttime audio recordings, and their contribution to predict imminent asthma exacerbation will be evaluated. Acceptability of the RespiSentinel app will be assessed through an app-based questionnaire. ResultsWe will train and validate an asthma exacerbation prediction model using multimodal data sources. This approach may help patients, their families, and health professionals anticipate upcoming loss of asthma control and take the necessary steps to prevent a severe asthma exacerbation. ConclusionsThe MoKA study will harness real-time mHealth data to identify children at imminent risk of asthma exacerbation with the ultimate goal of designing timely interventions to prevent morbidity in this group of patients.

CASE PRESENTATION:A 4-year-old girl with ring chromosome 14, epilepsy, global developmental delay, and failure to thrive presented for a preoperative assessment for gastrostomy tube (G-tube) insertion and was incidentally found to be hypoxemic, with saturations of 81% in room air. There was no history of fever or upper respiratory tract infection symptoms; however, her parents described a progressive history of choking and emesis with feeds over 3 months. Chest radiograph demonstrated patchy alveolar opacities in the right lower and middle lobes. She was admitted to the hospital and treated with supplemental oxygen and IV ampicillin for a suspected aspiration pneumonia. On day 3 of her admission, because of persistent hypoxemia despite high-flow nasal cannula support at 2 L/kg/min with an Fio2 of 0.6 to 0.7, and frequent need for suctioning of thick yellow secretions, she was transferred to the PICU for escalation to noninvasive ventilation. Because of poor response after 7 days, and respiratory secretions showing moderate growth of Klebsiella oxytoca and light growth of Stenotrophomonas maltophilia, sulfamethoxazole-trimethoprim was added. Azithromycin was also started on day 8 to cover atypical pathogens, then discontinued when Mycoplasma pneumoniae polymerase chain reaction was negative.

OBJECTIVE:The drastic decrease in pediatric asthma exacerbations at the beginning of the COVID-19 pandemic was assumed to be secondary to public health mitigation measures. However, this association has not been formally evaluated. We examined the correlation between the incidence of pediatric asthma hospitalizations in Canada and the stringency index (SI), a measure of the severity of public health mitigation measures, during the first two years of the COVID-19 pandemic. DESIGN:Ecological study from March 1st, 2020 to March 31st, 2022. Hospitalization data were obtained from a pan-Canadian inpatient administrative database and the SI was obtained from the Centre of Excellence on the Canadian Federation. We included children aged 1-17 years who were hospitalized for asthma. The association between the monthly number of asthma-related hospitalizations and the monthly average SI was evaluated using the Pearson correlation coefficient and negative binomial regression models. RESULTS:A total of 11,842 children were hospitalized for asthma. The monthly number of asthma-related hospitalizations was highly correlated with the SI (r = -0.73; 95 % CI -0.87, -0.47) and was the strongest for the initial pandemic period (March-June 2020, r = -0.99; 95 % CI -0.99, -0.82). A surge of hospitalizations was observed starting in May 2021, which coincided with the relaxation of public health measures. CONCLUSION:Using a pan-Canadian database, we demonstrated a strong negative correlation between the number of pediatric asthma-related hospitalizations and the stringency of public health mitigation measures. These findings are relevant for future epidemic and pandemic response strategies and resource allocation.

BackgroundInsufficient patient accrual is a major challenge in clinical trials and can result in underpowered studies, as well as exposing study participants to toxicity and additional costs, with limited scientific benefit. Real-world data can provide external controls, but insufficient accrual affects all arms of a study, not just controls. Studies that used generative models to simulate more patients were limited in the accrual scenarios considered, replicability criteria, number of generative models, and number of clinical trials evaluated. ObjectiveThis study aimed to perform a comprehensive evaluation on the extent generative models can be used to simulate additional patients to compensate for insufficient accrual in clinical trials. MethodsWe performed a retrospective analysis using 10 datasets from 9 fully accrued, completed, and published cancer trials. For each trial, we removed the latest recruited patients (from 10% to 50%), trained a generative model on the remaining patients, and simulated additional patients to replace the removed ones using the generative model to augment the available data. We then replicated the published analysis on this augmented dataset to determine if the findings remained the same. Four different generative models were evaluated: sequential synthesis with decision trees, Bayesian network, generative adversarial network, and a variational autoencoder. These generative models were compared to sampling with replacement (ie, bootstrap) as a simple alternative. Replication of the published analyses used 4 metrics: decision agreement, estimate agreement, standardized difference, and CI overlap. ResultsSequential synthesis performed well on the 4 replication metrics for the removal of up to 40% of the last recruited patients (decision agreement: 88% to 100% across datasets, estimate agreement: 100%, cannot reject standardized difference null hypothesis: 100%, and CI overlap: 0.8-0.92). Sampling with replacement was the next most effective approach, with decision agreement varying from 78% to 89% across all datasets. There was no evidence of a monotonic relationship in the estimated effect size with recruitment order across these studies. This suggests that patients recruited earlier in a trial were not systematically different than those recruited later, at least partially explaining why generative models trained on early data can effectively simulate patients recruited later in a trial. The fidelity of the generated data relative to the training data on the Hellinger distance was high in all cases. ConclusionsFor an oncology study with insufficient accrual with as few as 60% of target recruitment, sequential synthesis can enable the simulation of the full dataset had the study continued accruing patients and can be an alternative to drawing conclusions from an underpowered study. These results provide evidence demonstrating the potential for generative models to rescue poorly accruing clinical trials, but additional studies are needed to confirm these findings and to generalize them for other diseases.

OBJECTIVES:We aimed to develop a clinical risk score to predict future asthma acute care visits [emergency department (ED) visits or hospitalizations] within 1 year following a discharge from 1 of 2 tertiary care pediatric EDs in Ontario, Canada. METHODS:We assembled a nested Ontario cohort from the multicenter prospective DOORWAY cohort study and included children 1 to 17 years of age, with an ED visit for a moderate/severe asthma exacerbation. We linked this with provincial health administrative data. We used multivariable regression to derive and internally validate a practical clinical risk score to predict future asthma acute care visits. RESULTS:A total of 257 children [32% female, median age 3.0 years (IQR 1 to 7 y)] were included, and 58 experienced an asthma visit within the following year. These were best predicted by 4 factors: food allergy (OR 4.2, 95% CI: 1.2-14.9), family history of asthma (OR 0.5, 95% CI: 0.3-0.9), prior acute asthma medical visits (OR 2.8, 95% CI: 0.9-8.6), and prior emergency room visits for any respiratory diagnosis (OR 3.0, 95% CI: 1.4-6.4). A score of 0, 1, or 2 points was applied to each factor for up to a maximum of 6 points; the PARKA score has very good overall performance with a scaled Brier score of 0.11 on internal validation and good discrimination with an AUC of 0.72 (95% CI: 0.64-0.78). CONCLUSIONS:The PARKA score predicts the risk of a future asthma acute care visit in a cohort of Ontario children with a moderate/severe asthma ED visit. Following external validation, this tool may aid ED clinicians in accurately targeting resource-intensive preventative interventions for at-risk children.

INTRODUCTION:Asthma is a leading cause of chronic disease in children, and poor control is often associated with a lack of asthma knowledge, which can be improved through education. Thus, it is important to have a validated tool that measures asthma knowledge. We aimed to develop an asthma knowledge tool to assess the efficacy of comprehensive asthma education for caregivers of children with asthma. METHODS:An asthma knowledge tool was designed using existing questionnaires and pilot tested amongst 10 asthma experts and 20 parents who had previously received asthma education. The Children's Hospital of Eastern Ontario Asthma Knowledge Tool (CHAT) consists of 35 true/false questions. The CHAT was then prospectively administered to caregivers between June 2021 and 2023 before receiving education, < 7 days following education, and < 2 weeks after completing posttest 1. Internal responsiveness of the CHAT was measured by comparing pre- and posttest scores using paired t-tests and determining effect size. Test-retest reliability was calculated using the two-way mixed effect Intraclass correlation coefficient (ICC) for posttest scores. RESULTS:Mean CHAT scores amongst 129 participants increased by 6.2 points between pretest to posttest 1 (95% CI 5.4-7.0), with an estimated effect size of 1.2, indicating a large change (p < 0.001). Test-retest reliability was "good" to "excellent" with an estimated ICC of 0.85 between posttests. CONCLUSION:The CHAT exhibited good discrimination, and reliably measured a significant improvement in knowledge scores following asthma education. The CHAT is a validated asthma knowledge tool for caregivers of children with asthma, having implications for future quality improvement and research studies.

Objectives: We aimed to develop a clinical risk score to predict future asthma acute care visits [emergency department (ED) visits or hospitalizations] within 1 year following a discharge from 1 of 2 tertiary care pediatric EDs in Ontario, Canada. Methods: We assembled a nested Ontario cohort from the multicenter prospective DOORWAY cohort study and included children 1 to 17 years of age, with an ED visit for a moderate/severe asthma exacerbation. We linked this with provincial health administrative data. We used multivariable regression to derive and internally validate a practical clinical risk score to predict future asthma acute care visits. Results: A total of 257 children [32% female, median age 3.0 years (IQR 1 to 7 y)] were included, and 58 experienced an asthma visit within the following year. These were best predicted by 4 factors: food allergy (OR 4.2, 95% CI: 1.2-14.9), family history of asthma (OR 0.5, 95% CI: 0.3-0.9), prior acute asthma medical visits (OR 2.8, 95% CI: 0.9-8.6), and prior emergency room visits for any respiratory diagnosis (OR 3.0, 95% CI: 1.4-6.4). A score of 0, 1, or 2 points was applied to each factor for up to a maximum of 6 points; the PARKA score has very good overall performance with a scaled Brier score of 0.11 on internal validation and good discrimination with an AUC of 0.72 (95% CI: 0.64-0.78). Conclusions: The PARKA score predicts the risk of a future asthma acute care visit in a cohort of Ontario children with a moderate/severe asthma ED visit. Following external validation, this tool may aid ED clinicians in accurately targeting resource-intensive preventative interventions for at-risk children.

BACKGROUND:Adenotonsillectomy and tonsillectomy (referred to as tonsillectomy hereafter) are common pediatric surgeries. Postoperative complications include hemorrhage requiring surgery (2 to 3% of cases) and pain. Although nonsteroidal anti-inflammatory drugs are commonly administered for postsurgical pain, controversy exists regarding bleeding risk with cyclooxygenase-1 inhibition and associated platelet dysfunction. Preliminary evidence suggests selective cyclooxygenase-2 inhibitors, for example celecoxib, effectively manage pain without adverse events including bleeding. Given the paucity of data for routine celecoxib use after tonsillectomy, this study was designed to investigate the association between postoperative celecoxib prescription and post-tonsillectomy hemorrhage requiring surgery using chart-review data from the Children's Hospital of Eastern Ontario. METHODS:After ethics approval, a retrospective single-center observational cohort study was performed in children less than 18 yr of age undergoing tonsillectomy from January 2007 to December 2017. Cases of adenoidectomy alone were excluded due to low bleed rates. The primary outcome was the proportion of patients with post-tonsillectomy hemorrhage requiring surgery. The association between a celecoxib prescription and post-tonsillectomy hemorrhage requiring surgery was estimated using inverse probability of treatment weighting based on propensity scores and using generalized estimating equations to accommodate clustering by surgeon. RESULTS:An initial patient cohort of 6,468 was identified, and 5,846 children with complete data were included in analyses. Median (interquartile range) age was 6.10 (4.40, 9.00) yr, and 46% were female. In the cohort, 28.1% (n = 1,644) were prescribed celecoxib. Among the 4,996 tonsillectomy patients, 1.7% (n = 86) experienced post-tonsillectomy hemorrhage requiring surgery. The proportion with post-tonsillectomy hemorrhage requiring surgery among patients who had a tonsillectomy and were or were not prescribed celecoxib was 1.94% (30 of 1,548; 95% CI, 1.36 to 2.75) and 1.62% (56 of 3,448; 95% CI, 1.25 to 2.10), respectively. Modeling did not identify an association between celecoxib prescription and increased odds of post-tonsillectomy hemorrhage requiring surgery (odds ratio = 1.4; 95% CI, 0.85 to 2.31; P = 0.20). CONCLUSIONS:Celecoxib does not significantly increase the odds of post-tonsillectomy hemorrhage requiring surgery, after adjusting for covariates. This large pediatric cohort study of celecoxib administered after tonsillectomy provides compelling evidence for safety but requires confirmation with a multisite randomized controlled trial. EDITOR’S PERSPECTIVE:

Objectives:Primary care practitioners (PCPs) report that using the Champlain BASE™ eConsult service (eConsult) averts one-third of face-to-face (FTF) specialist referrals, however, there are concerns about duplication of services and adverse patient outcomes. Following an eConsult, we evaluated patient healthcare utilization and associated treatment costs. Methods:Retrospective cohort study (2014 to 2018) of patients (<18 years old) for whom an eConsult visit averted a FTF specialist referral. Patients were linked to provincial health administrative databases and hospital electronic medical records for healthcare use for the same diagnosis and specialty for the 18 months following the eConsult. Concurrently, a retrospective case-control study compared utilization and costs between an eConsult versus a matched FTF visit for the same diagnosis. We also assessed PCP satisfaction. Results:In follow-up, <5% of the study cohort of eConsult patients (n = 242) later accessed the healthcare system for the identical diagnosis and specialty type. FTF visits generate more frequent outpatient visits (12.6 times more [95% CI: 2.28 to 69.66, P = 0.002]) and higher costs compared to eConsult visits. There were no hospital admissions or deaths in patients with eConsult. PCPs (98%) described eConsult as an excellent service. Conclusions:Using eConsult is associated with <5% of patients subsequently having a FTF visit for the same reason. Matched FTF visits generated more healthcare utilization and higher costs compared with eConsult. eConsult in pediatrics is safe and can minimize FTF specialist visits in elective cases and increase capacity, towards a more efficient and cost-effective healthcare system.

Abstract Background Despite asthma guidelines’ recommended emergency department preventative strategies (EDPS), repeat asthma-related emergency department (ED) visits remain frequent. Methods We performed a retrospective cohort study of children aged 1–17 years presenting with asthma to the Children’s Hospital of Eastern Ontario (CHEO) ED between September 1, 2014 – August 31, 2015. EDPS was defined as provision of education on trigger avoidance and medication technique plus documentation of an asthma action plan, a prescription for an inhaled controller medication or referral to a specialist. Logistic regression was used to identify factors associated with receipt of EDPS. We further compared the odds of repeat presentation to the ED within the following year among children who had received EDPS versus those who had not. Results 1301 patients were included, and the mean age of those who received EDPS was 5.0 years (SD = 3.7). Those with a moderate (OR = 3.67, 95% CI: 2.49, 5.52) to severe (OR = 3.69, 95% CI: 2.50, 5.45) asthma presentation were most likely to receive EDPS. Receiving EDPS did not significantly reduce the adjusted odds of repeat ED visits, (OR = 0.82, 95% CI: 0.56, 1.18, p = 0.28). Conclusions Patients with higher severity asthma presentations to the ED were more likely to receive EDPS, but this did not appear to significantly decrease the proportion with a repeat asthma ED visit. These findings suggest that receipt of EDPS in the ED may not be sufficient to prevent repeat asthma ED visits in all children.

BACKGROUND:Self-management education is integral for proper asthma management. However, there is an accessibility gap to self-management education following asthma hospitalizations. Most pediatric patients and their families receive suboptimal or no education. OBJECTIVE:To implement a comprehensive pediatric asthma education program and evaluate subsequent self-management knowledge in patients as well as behavior change outcomes reflected in the frequency of asthma related repeat emergency department visits and hospitalization. The program implementation was informed by the Knowledge to Translation Action Framework and the i-PARIHS model for quality improvement and involved several iterative stages. METHODS:We implemented a comprehensive asthma education program for the families of all children 0-18 years old who had been admitted for an asthma exacerbation to the Children's Hospital of Eastern Ontario (CHEO), beginning on April 1, 2018. The program was adapted to the stages of the Knowledge Translation to Action Framework including undertaking an environmental scan, expert stakeholder feedback, reviews, addressing barriers, and tailoring the intervention, along with evaluating knowledge and health outcomes. Education was delivered over 1-2 h in personalized individual or small group settings, within 4 wk of hospital discharge. All education was provided by registered nurses or respiratory therapists who were also certified asthma educators. The EPIC electronic medical record was used to facilitate referral and scheduling of asthma education sessions, and to track subsequent acute asthma visits. We compared the frequency of a repeat asthma emergency department (ED) visit or hospitalization within 1-year following an initial asthma hospitalization for children who would have received comprehensive asthma education, to a historical cohort of children who were hospitalized between April 9, 2017 - Apr 8, 2018, and did not receive asthma education. RESULTS:The program had a high enrollment, capturing nearly 75% of the target population. Most families found the program to be acceptable and reported increased knowledge of how to manage asthma. We identified a crude overall 54% reduction in repeat hospitalizations among children 1 year after implementation of the asthma education program (i.e. 10.2% (23/225) repeat hospitalization rate pre- implementation versus 4.8% (11/227) post-implementation). In adjusted time-to event analysis, this reduction was prominent at 3 months among those who received comprehensive asthma education, relative to those who did not, but this improvement was not sustained by 1 year (HR =1.1, 95% CI =0.55- 2.05; p-value = 0.6). DISCUSSION:Although we did not find long-term improvements in ED visits, or hospitalizations, in children of caregivers who participated in comprehensive asthma education, the asthma education program holds potential given that most patients found it to be acceptable and that it increased asthma management knowledge. A future asthma education program should include multiple sessions to ensure that the knowledge and behavior change will be sustained, leading ultimately to long-term reductions in repeat ED visits and hospitalizations.

Abstract Background Paediatric emergency department (ED) asthma guidelines recommend the administration of short-course systemic corticosteroids (SCS) for moderate to severe asthma exacerbations. The potential adverse implications of frequent, short-course SCS in children are poorly characterized. Objectives To determine the risk of adverse outcomes in children with asthma who receive multiple short-courses of SCS for asthma exacerbation management. Design/Methods In this population-based, retrospective cohort study, we identified children aged 1-16 years with an ED asthma presentation/hospitalization between October 1, 2017, and February 28, 2020. We divided participants into an SCS-exposed and unexposed cohort. A minimum washout period of 3 years was applied to exclude any SCS use before the index date. During a 24-month follow-up period, we captured cumulative short-courses of SCS for acute asthma management and the primary outcome, development of steroid-associated complications. We excluded participants with steroid-treated comorbidities, non-asthma-related SCS exposure and development of adverse outcome(s) before the index visit. We compared baseline characteristics between cohorts using descriptive statistics. A Prentice-Williams-Peterson model was used to determine the risk of adverse outcomes amongst children receiving SCS for asthma management with results expressed as adjusted hazard ratios (HR) and 95% Wald confidence intervals (CI). Results We identified 1468 participants with an asthma ED visit who received ≥1 SCS course for acute management and 541 participants who did not receive SCS during our study window, after applying inclusion/exclusion criteria. Baseline demographics were balanced between cohorts aside from age at index, which was significantly younger (4.31 ± 3.71 vs 7.64 ± 4.21 p<0.001) in the SCS-exposed cohort. Overall, the risk of developing a recurrent SCS-associated adverse outcome was not increased in the SCS-exposed cohort (HR = 0.95, 95% CI: 0.74-1.23, p=0.7). However, when the number of SCS courses was considered, a significant risk of recurrent SCS-associated outcomes emerged, especially for those receiving 4+ SCS courses (HR = 2.30, 95% CI: 0.92-5.80). This potential dose-response effect was negated when patients who were likely on medium to high dose maintenance inhaled corticosteroids, were removed in a sensitivity analysis (HR = 1.38, 95% CI: 0.35-5.39). Conclusion At a tertiary care Canadian paediatric hospital, children and adolescents receiving short-course SCS for asthma exacerbation management overall do not demonstrate an increased risk of developing complications after two years follow-up. However, complication risk may be increased among those receiving 4+ cumulative SCS courses.