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Research Happening Now in the Emergency Department at CHEO

Magnesium Nebulization Utilization in Management of Pediatric Asthma – “MagNUM PA”

Acute asthma is the most common cause of pediatric hospitalizations. While we know that repeat inhalations of bronchodilator’s with early oral steroids substantially reduce hospitalizations, many children are resistant to this standard initial therapy. About a third of children remaining in moderate to severe distress after standard therapy are admitted to hospital and comprise 84% of pediatric acute asthma hospitalizations. Finding safe, non-invasive, and effective strategies to treat children resistant to standard therapy would substantially decrease hospitalizations resulting in considerable health care savings and reduction of the psycho-social burden of the disease. While studies of magnesium sulfate (Mg) given intravenously (IV) suggest that this agent can reduce hospitalizations in both adults and children resistant to standard initial therapy, a North America-wide survey completed by us shows that only 7% of Emergency Department (ED) physicians give IV Mg to prevent hospitalizations. Nebulization (inhalation) is an alternate route for administering Mg. This route has the advantage of being non-invasive and is likely much safer due to lower systemic delivery. Direct delivery via nebulization allows higher Mg concentrations at the target site, the lower airways, with a smaller total drug dose. This definitive trial of children in significant respiratory distress after optimized initial therapy will assess the impact of inhaled Mg on hospitalizations, use of medical resources and additional rescue co-interventions.

UPDATE: This study started enrollment in September and more than 283 families are currently enrolled in the trial.

How Safe are our Pediatric Emergency Departments? A National Prospective Cohort Study

Patient safety has been identified internationally as a health care priority.1,2 Adverse events (AEs), broadly defined as unintended harm to the patient that is related to health care and/or services provided to the patient rather than the patient’s underlying medical condition,3 represent a significant threat to patient safety and public health. To date, patient safety research has focused on admitted patients. However, most Canadians, and especially children, are more likely to visit an Emergency Department (ED) than to be admitted to hospital. . Little research has been conducted on pediatric patient safety in the ED. We have no evidence about how common AEs are among children seen and treated in EDs in children’s hospitals. Such knowledge is an essential first step to understand how to improve the safety of pediatric EDs and ultimately children’s health outcomes.

The purpose of this study is to better understand patient safety in the emergency department. Specifically we want to learn about the frequency, severity and preventability of adverse events occurring among children in the emergency department. This information will help us to improve the safety of emergency department care for all Canadian children.

UPDATE: Enrollment in this study is now complete. More than 800 families participated in this trial. Our findings will be published in the coming year.

Impact of Emergency Department Probiotic Treatment of Pediatric Gastroenteritis Randomized Controlled Trial

This National study is being done to improve the care of children who have acute gastroenteritis. Acute gastroenteritis is an infection or irritation of the digestive tract, particularly the stomach and intestine. It causes diarrhea and vomiting, as well as possible fever, nausea, stomach pains or cramps, and other symptoms. It is frequently referred to as the stomach flu or intestinal flu. Usually no medication is recommended for the treatment of gastro,. however, early research has shown that taking a probiotic, which are bacteria that are good for people, might help children with diarrhea and/or vomiting, stop sooner. Since we do not know if probiotics are helpful when given to children with mild diarrhea and vomiting, we do not know if giving a probiotic to children will reduce symptoms. The goal of this study is to find out if taking Lacidofil®, a specific type of probiotic, will reduce the severity of gastro symptoms in children who come to the emergency department. Our research team hopes to recruit approximately 180 children from CHEO. The study is also being conducted at four other pediatric hospitals in Canada. In total, 886 children will be recruited from the five hospitals.

UPDATE: Enrollment is now completed and analysis of the data is underway! Stay tuned for the results.
Short-Course Antimicrobial Therapy for Paediatric Respiratory Infection (SAFER)

Despite how common paediatric pneumonia is, the optimal duration of antibiotic treatment for it has not been defined; the Infectious Disease Society of America currently recommends 10 days of treatment for mild pneumonia but they note that this guideline is based on very little evidence. This is an important question to address because determining the proper length of antibiotic treatment for a given condition is extremely important. Giving too few days of antibiotics for an infection is obviously problematic; however, giving too many days of antibiotics can also lead to harm, including more drug side-effects, more antibiotic resistance in the population at large, more disruption of the body’s normal bacterial flora, and higher drug costs for families. The goal of this study is to determine whether fewer days of amoxicillin, the first-line recommended antibiotic in children, is an acceptable alternative to 10 days of amoxicillin for the treatment of mild paediatric pneumonia.

UPDATE: This study is currently enrolling patients at CHEO Emergency Department. 30 families have participated so far.
photo of baby with a happy face
Improving the treatment of Allergic Reactions
The use of infographics or pictures, can improve patient comprehension, treatment compliance, and retention of counselling points, which are key components to improving the management of severe allergic reactions. To date, there are no satisfactory pictorial aids that explain the treatment and management of pediatric anaphylaxis.
CHEO researchers are currently enrolling patients in our Emergency Department with severe allergic reactions into a study that will lead to the development of an illustrated Anaphylaxis Action Plan and Counselling Tool (AAP) that could serve as a helpful tool for families along with the usual verbal counselling and written materials they receive when they are treated at CHEO.
The aim of this study is to evaluate parental and teenagers' knowledge about anaphylaxis management after receiving an illustrated Anaphylaxis Action Plan & Counselling Tool. Readability, actionability and satisfaction with the AAP will also be assessed. 100 participants will be recruited in this study over the next few months.  
Pediatric Concussion Assessment of Rest and Exertion (PedCARE): A Study to Determine When to Resume Physical Activities Following Concussion in Children

CHEO Researchers are looking at Children aged 10-17 years old who present to the Emergency Department (ED) with a minor head injury.
We are interested in learning more about when is the best time to resume physical activity following a head injury. Concussion management for physical activity and rest is not currently based on research studies. While some experts recommend that children rest until having no symptoms before resuming physical activity other experts recommend resuming light physical activity sooner. Therefore, the current care is dependent on each person’s individual medical provider. This study will help to clarify and standardize the care

UPDATE: This study is underway and enrolling patients now.

Advancing Concussion Assessment in Pediatrics (A-CAP) Study

Clinicians urgently need evidence-based guidance to manage concussions in children.
The diagnosis and prognosis of concussion lacks a gold standard, An approach that incorporates both neurobiological and psychosocial markers is needed for effective diagnosis and prognosis. Innovative research is needed to improve assessment of concussion.

The research will enhance our understanding of pediatric mild traumatic brain injury.

The research also will improve the clinical care and outcomes of children with concussion.

UPDATE: This study is up and running and has recruited 129 young people and their families so far.
Oral Dexamethasone for the Prevention of Migraine Recurrence in the Pediatric ED: A Pilot Trial

More than 300 children come to the emergency department at CHEO each year to be treated for migraines. Research in adults has shown that steroids help in preventing reoccurrence of migraines but there is no evidence for children yet. CHEO researchers are looking to determine the feasibility of carrying out a trial to assess the efficacy of a very common liquid medication (steroid) for preventing migraine recurrence in the pediatric ED.

UPDATE: Enrollment in this trial is now complete and analysis of the data is underway. We hope to be able to share results in the coming months.
Derivation of a clinical score to predict risk of future emergency department visits and hospitalizations among children with asthma
Currently, most children who leave the ED after an asthma visit do not receive proven preventative treatments such as asthma education.  However, these treatments are only needed for children at high-risk for repeat visits. There are no guidelines to direct clinicians how to practically identify these high-risk children before discharge from the ED. With this study, researchers will derive a clinical risk score to identify children at high-risk for repeat asthma visits within a year after a first asthma ED visit. Data collected from a previous study of children visiting the ED for asthma will be analyzed. The information on participants of this previous study will be linked with Ontario and Quebec health administrative data to identify repeat ED or hospital visits over the following year. This will enable development of a clinical score to identify high-risk asthma patients. Importance: This study will provide a method to identify children at high risk for future asthma ED visits or hospitalizations and in future, to target treatments to children who would benefit most.
UPDATE: Data analysis underway
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