Hospital News August 2021 Edition by Hospital News

Inside: From the CEO’s Desk | Evidence Matters | Safe Medication | Special focus: Paediatrics

August 2021 Edition

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Contents August 2021 Edition

IN THIS ISSUE:

Seniors DANCE program waltzes across Canada

▲ Cover story: Special focus on paediatrics

▲ The impact of COVID-19

▲ Building inspiring healthy futures: A partnership for children, youth and families in Canada

COLUMNS Editor’s Note ....................4 In brief ..............................6

Long-term Care ...............26 Safe medication ............28

▲ Neurovascular team performs novel brain aneurysm procedure

From the CEO’s desk .....29 Evidence matters ...........30

▲ Identifying unique characteristics of human neurons

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AUGUST 2021 HOSPITAL NEWS 3

Myocarditis and pericarditis and the COVID-19 vaccine

n late May 2021, the World Health Organization vaccine safety committee noted that myocarditis and pericarditis following vaccination with COVID-19 mRNA vaccines are events of special interest for continued evaluation. A small number of case series have emerged from Israel and the United States. The US Centres for Disease Control and Prevention provided recommendations for clinicians and on June 10th presented safety assessments to the Food and Drugs Administration in readiness of review of emergency use authorization of the Moderna mRNA vaccine in adolescents. Available information indicates that: • Symptom onset was usually within a few days after vaccination • Cases were mainly male adolescents and young adults after the second dose; in the US data the median age of cases following 2nd dose was 24 years • Most cases experienced mild illness, responded well to conservative treatment and rest, and their symptoms improved quickly. In the US data analyses, the observed cases exceeded the expected number of cases (based on background rates of myocarditis) following the 2nd dose in the age group 16-24 years. The estimated rate of myocarditis was about 16 cases per million 2nd doses (35 per million in 16-17 year olds; 21 per million in 18-24 year olds). While nine per cent of doses were

administered in the 12-24 year age group, this group accounted for 53 per cent of myocarditis reports following the 2nd dose. To date, no regulatory action has been taken in Canada or internationally. Additional discussion including a benefit risk assessment are scheduled for review at the US Advisory Committee on Immunization Practices on June 18th.

SITUATION IN CANADA AND BC

As part of ongoing COVID-19 vaccine safety efforts, BC Centre for Disease Control (BCCDC) along with local medical health officers, the Public Health Agency of Canada (PHAC) and Health Canada are closely monitoring myocarditis/pericarditis in passive and active Canadian safety surveillance systems, including the Canadian Adverse Events Following Immunization Surveillance System (CAEFISS), the Canada Vigilance Program, the Canadian National Vaccine Safety Network (CANVAS) and the Canadian Immunization Monitoring Program ACTive. In BC and elsewhere in Canada, there have been a small number of reports of pericarditis or myocarditis following vaccination with a COVID-19 mRNA vaccine. In Canada and BC to date, higher rates than would be expected have not yet been observed. The weekly Canadian and BC adverse events following COVID-19 vaccine reports provide updates on the latest numbers.

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NEWS

Doctors urging health-care workers to do the right thing and get vaccinated By Dr. Adam Kassam n a recent Ontario Medical Association survey, we asked Ontario’s doctors to tell us if they had been vaccinated. A full 98 per cent of those who responded said they had. This is a clear reflection of physicians’ steadfast belief in the effectiveness of vaccines in leading Ontario, Canada and indeed the world out of the COVID-19 pandemic. As doctors, we have reviewed (in some cases, developed) the science behind the vaccines being offered to fight this deadly virus, and vaccines unequivocally have our endorsement. In rolling up our own sleeves to get the jab, we are taking care of ourselves, our patients and our communities. Now, we are strongly urging not just our patients, but the entire medical community — anyone who works in health care — to follow suit. While it’s possible that the rate of vaccination among health-care workers is already higher than among the general population, we are nevertheless concerned that even a single person who spends their days or nights caring for the sick and injured, or anyone involved in preventative medicine, or diagnostic testing would hesitate to seek out the vaccines that are so obviously saving lives and reducing serious illness. We are calling on all health-care workers to have the COVID-19 vaccination and believe strongly that this should be mandatory so that everyone involved in health care may protect their own health as well as the health of the patients they serve and the people around them. The science shows vaccines are the best way to control the spread of COVID-19 and are an essential component in personal and community health. In the most recent data available, Ontario’s chief medical officer of health said that nearly 80 per cent of Ontario’s eligible population had received at least one dose of a COVID-19 vaccine.

To say the past 17 months has been challenging is an understatement. Too many people lost their lives. Husbands buried wives, and vice versa. There are sons and daughters without parents and young people without grandparents. Some of those who survived are experiencing long-term effects. Jobs were lost, or put on hold. Children lived in isolation from their friends. Family connections were broken. Mental health issues and addictions are on the rise.

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Dr. Kieran Moore also said modelling suggests that a vaccination rate of 90 per cent among the eligible population of Ontarians aged 12-plus may be required to protect us from the emerging and extremely contagious Delta variant, which has grown dominant in Ontario. While infection rates remain much lower than at the peak of the pandemic’s third wave, people are still contracting COVID-19. Many are still seeking out a doctor. Some of those patients are requiring hospitalization. Regrettably, some are still dying. Public Health Ontario has estimated that the risk of contracting COVID-19 in June was 4.7 times higher for unvaccinated people, compared to those fully vaccinated, and 3.4 times higher than for those who have had a single dose. Among those who contract the virus, the risk of being hospitalized is three times higher than for those who have received at least one shot.

school. Young adults can safely go back to college, or university. Workplaces can re-open. Families can reunite. All without over burdening our intensive care units and health-care system more generally. Without reaching a higher rate of overall vaccination, unvaccinated people are vulnerable and pose a threat to those who have had their shots, especially to our older community and those who are immune-suppressed, or otherwise vulnerable. Without vaccinated health-care workers, we risk infecting vulnerable children under 12 who need our care.

NO ONE WANTS THE PANDEMIC TO CONTINUE ANY LONGER THAN NECESSARY

My message to the 2.4 million Ontarians who are eligible to be vaccinated but haven’t yet done so is to talk to your doctor, get informed, and get the shot as soon as possible. To those who have had one dose, and not the second. Make an appointment now. To health-care workers, I say it’s your duty to protect yourself and protect others. Don’t wait for it to be mandatory to be vaccinated. Whether that happens or not, do the right thing, and get your first and second dose. You owe it to yourselves, your family and to H those you care for. ■

Dr. Adam Kassam is President of the Ontario Medical Association.

MAXIMIZING VACCINATION RATES WILL ALLOW ONTARIO TO MOVE TOWARD NORMALCY

The virus simply cannot spread widely when most of the population is immune. Children can return to AUGUST 2021 HOSPITAL NEWS 5

IN BRIEF

Preparing for the next pandemic T

o prepare for the next pandemic and provide a coordinated approach to vaccination across the country, Canada should create Canadian Immunization Services based on the Canadian Blood Services model, authors propose in CMAJ (Canadian Medical Association Journal). The authors, including a leading health policy and immunization expert, a blood system expert and a former federal minister of health, are

Dr. Kumanan Wilson, professor, Department of Medicine and member of the Centre for Health Law, Policy and Ethics, University of Ottawa; Dr. Graham Sher, CEO, Canadian Blood Services; and Dr. Jane Philpott, Dean, Faculty of Health Sciences, Queen’s University. “If we want to be better prepared for the next pandemic, it is time to chart a bold new path forward,” said Dr. Kumanan Wilson. “We propose intergovernmental collaboration through

Myocarditis Continued from page 4

DIAGNOSIS AND REPORTING

Myocarditis and pericarditis involve inflammation of the heart in response to an infection or some other trigger. Symptoms can include shortness of breath, chest pain, or the feeling of a rapid or abnormal heart rhythm. Healthcare providers should consider myocarditis and pericarditis in evaluation of acute chest pain or pressure, documented arrhythmia, shortness of breath or other clinically compatible symptoms after vaccination. They should consider doing an electrocardiogram (ECG) and measuring, troponins, BNP (brain natriuretic peptide), and C-reactive protein (CRP) when available. If these markers are consistent with myocardial involvement and an acute coronary syndrome is not high on the differential, testing for acute COVID-19 infection (e.g., PCR testing), prior SARS-CoV-2 infection (e.g., detection of SARS-CoV-2 spike and nucleocapsid antibodies), and other viral etiologies (e.g., respiratory viruses associated with myocarditis) are recommended in consultation with the BCCDC Medical Microbiologist (telephone 604-661-7033). It should be noted that troponins, BNP and CRP are non-specific biomarkers and may be elevated in a number of non-cardiac medical conditions. If concern for myocarditis or pericardi-

tis persists, an echocardiogram can be undertaken in consultation with cardiology at BC Children’s (telephone 604-875-2161), or an adult cardiology care provider as appropriate. While the gold standard(s) for diagnosing myocarditis is cardiac MRI, PET or endomyocardial biopsy, these will typically not be necessary in an otherwise well adolescent or young adult. Consultation can be sought with infectious disease and/or rheumatology if other etiologies are being considered. All cases of myocarditis or pericarditis following vaccination should be reported to the local health authority. BCCDC and other Canadian public health authorities will continue to closely monitor reports of myocarditis and/or pericarditis. Health Canada is also working closely with the manufacturers and international regulators to review information as it becomes available and will take appropriate action as needed. More information will be shared as it becomes available. The benefits of the mRNA vaccines continue to outweigh their risks including in adolescent populations. Parents, teens and young adults should be reassured that these events are rare and typically associated with mild illness and full recovery. There are clear benefits of mRNA vaccines in reducing infection and transmission as well as hospitalizations and deaths H due to COVID-19 infections. ■

This letter was provided by the BC Centre for Disease Control. 6 HOSPITAL NEWS AUGUST 2021

an arms-length entity, which was successful after the tainted blood scandal, one of Canada’s biggest public health crises. We have done this before, emerging stronger from a public health crisis and creating a world-class blood system. We can do it again.” Various reports, including from the federal auditor general, have documented the problems with how Canada’s federal, provincial and territorial governments work together. Different vaccination schedules for each province and territory, different terminology and variations in immunization tracking have made Canada’s system fragmented. “It is challenging to coordinate pan-Canadian disease surveillance and mass immunization responses without harmonized data and systems,” said Dr. Wilson. “Our response to COVID-19 has been plagued by many of the challenges facing public health over the last 20 years.” As the responsibility for managing public health threats is largely the responsibility of the provinces and territories, unilateral federal mandates are difficult to implement. The authors propose an independent not-for-profit corporation — Canadian Immunization Services — funded by participating provinces and territories, and potentially the federal government, based on the Canadian Blood Services model.

Anticipate a resurgence of respiratory viruses in young children anada should anticipate a resurgence of a childhood respiratory virus as COVID-19 physical distancing measures are relaxed, authors warn in CMAJ (Canadian Medical Association Journal). Cases of respiratory syncytial virus (RSV) have risen sharply in Austra-

“Twenty-three years ago, Canadian Blood Services assumed full responsibility for the operation of the national blood supply outside Quebec, taking over a system that was unquestionably broken,” said Dr. Graham Sher. “We were founded to restore confidence in the blood system, and over the past two decades, our journey has been one from tragedy to trust. We now have one of the safest blood systems in the world. We believe that Canada can effectively prepare for the next pandemic by establishing a world-class vaccination system based on this model as well.” Canadian Immunization Services would provide: • Ability to procure vaccines in bulk for Canada • Vaccine surveillance and supply chain management by single entity versus many • Common data standard to enable data sharing between provinces and territories • Ability to access expertise rapidly without government barriers to hiring “If we hope for public health to be better prepared for the next pandemic, now is the time to implement needed changes,” the authors conclude. “Preparing for the next pandemic by creating Canadian Immunization SerH vices” was published July 19, 2021. ■

lia and, more recently, the United States as COVID-19 case counts have waned and pandemic public health measures have been relaxed. Respiratory syncytial virus affects the lower respiratory tract and can cause serious illness and death. Before the COVID-19 pandemic, about 2.7 million children worldwide were infected with RSV each year, and it was the fourth most common cause of death in young children. “The off-season resurgence in seasonal respiratory viruses now potentially poses a threat to vulnerable infants,” writes Dr. Pascal Lavoie, BC Children’s Hospital Research Institute and the University of British Columbia, Vancouver, BC, with coauthors. www.hospitalnews.com

IN BRIEF

New WHO study links moderate alcohol use with higher cancer risk A

new study from the World Health Organization’s (WHO) International Agency for Research on Cancer (IARC), published in the journal Lancet Oncology, has found an association between alcohol and a substantially higher risk of several forms of cancer, including breast, colon, and oral cancers. Increased risk was evident even among light to moderate drinkers (up to two drinks a day), who represented 1 in 7 of all new cancers in 2020 and more than 100,000 cases worldwide. In Canada, alcohol use was linked to 7,000 new cases of cancer in 2020, including 24 per cent of breast cancer cases, 20 per cent of colon cancers, 15 per cent of rectal cancers, and 13 per cent of oral and liver cancers.

“All drinking involves risk,” said study co-author Dr. Jürgen Rehm, Senior Scientist, Institute for Mental Health Policy Research and Campbell Family Mental Health Research Institute at CAMH. “And with alcohol-related cancers, all levels of consumption are associated with some risk. For example, each standard sized glass of wine per day is associated with a 6 per cent higher risk for developing female breast cancer.” “Alcohol consumption causes a substantial burden of cancer globally,” said Dr. Isabelle Soerjomataram, Deputy Branch Head, Cancer Surveillance Branch at IARC. “Yet the impact on cancers is often unknown or overlooked, highlighting the need for implementation of effective policy and inter-

ventions to increase public awareness of the link between alcohol use and cancer risk, and decrease overall alcohol consumption to prevent the burden of alcohol-attributable cancers.” Dr. Leslie Buckley, CAMH Chief of Addictions, added: “In our clinic we are seeing many people who report increased alcohol use since the onset of the pandemic. Although this may be related to temporary stressors, there is a potential for new habits to become more permanent. The consequences with alcohol use are often subtle harms initially that take time to show themselves, while long-term consequences such as cancer, liver disease and substance use disorder can be devastating.” The modelling study was based on data on alcohol exposure from al-

most all countries of the world, both surveys and sales figures, which were combined with the latest relative risk estimates for cancer based on level of consumption. “Alcohol causes cancer in numerous ways,” explained Dr. Kevin Shield, Independent Scientist, Institute for Mental Health Policy Research, and study co-author. “The main mechanism of how alcohol causes cancer is through impairing DNA repair. Additional pathways include chronic alcohol consumption resulting in liver cirrhosis, and alcohol leading to a dysregulation of sex hormones, leading to breast cancer. Alcohol also increases the risk of head and neck cancer for smokers as it increases the absorption H of carcinogens from tobacco.” ■

Reducing wait times for diagnostic tests, treatments and procedures is the top health-care priority educing wait times for diagnostic tests, treatments and procedures is the top health-care priority for Ontarians, according to interim results of an online survey conducted by the Ontario Medical Association.

During the COVID-19 pandemic, Canada, like other countries, has seen very few cases of RSV, with only 239 positive cases between August 29, 2020, and May 8, 2021, compared with 18,860 positive tests in a similar period the previous year (between August 25, 2019, and May 2, 2020). The virus seemed to disappear over the last year. However, an increased number of cases of RSV in Canada this summer, as in other jurisdictions, could stretch health care resources in pediatric intensive care units (ICUs). Most pregnant women and very young infants did not develop immunity in the previous season, so children may develop more severe illness this year. www.hospitalnews.com

Of the 4,200 Ontarians who have responded to the OMA’s survey so far, almost 25 per cent identified wait times as their No. 1 priority, confirming what the OMA has been hearing from patients, physicians, healthcare partners and others across the province.

In anticipation of a potential resurgence of RSV, the authors suggest: • Continued emphasis on handwashing and basic hygiene measures and other protective measures such as breastfeeding when possible • Continued testing to confirm RSV when required • Planning by pediatric ICUs to manage increases in severe RSV cases • Administering preventive treatment to highest-risk infants in the summer if cases increase to the level of the normal fall season. “Potential resurgence of respiratory syncytial virus in Canada” was H published July 26, 2021. ■

“Wait times were an issue before the pandemic and the situation has unfortunately gotten worse,” said OMA President Dr. Adam Kassam. “The impact of COVID-19 has led to almost 16 million health-care services having been delayed or deferred, which is more than one for every Ontario resident. It is, therefore, no surprise that this is the top health-care priority.” Patients had concerns about wait times even before the pandemic caused care to be delayed or deferred because of lockdown conditions or fears that going to hospitals would increase the risk of being exposed to COVID-19. Doctors and other health-care workers have been working on the front lines of the pandemic since it began. In addition to treating COVID patients, and catching up on surgeries, diagnostic exams and other procedures that could not take place during the pandemic, family physicians and community specialists are starting to see conditions that were undetected during the pandemic and will require treatment now. Some patients are being diagnosed with cancers, heart conditions or diabetes they didn’t know they had. Previously diagnosed chron-

ic conditions have grown more serious. Survey respondents were asked to identify one priority for improving health care in Ontario. While reducing wait times led the list, 19 per cent of survey respondents identified the need for more doctors as their priority, 17 per cent identified improvements to seniors’ health, including home care and longterm care, and 14 per cent said it was improved access to mental health services. The OMA will use the survey results along with input from doctors, health-care stakeholders and community leaders across Ontario to develop a plan for the future of health care in Ontario that will be released this fall. “These survey results will help Ontario’s doctors fix the cracks in the health-care system that the pandemic brought to light and to think through what the future of health care could and should look like,” said OMA CEO Allan O’Dette. “Ontario’s doctors are developing a plan that will include the bold ideas necessary to take us through the recovery phase and well into the future. It will take everyone – doctors, government, hospitals and allied health professionals – working together to fix H the backlog and reduce wait times.” ■ AUGUST 2021 HOSPITAL NEWS 7

NEWS

First-in-Canada social medicine modular housing niversity Health Network (UHN) and the Gattuso Centre for Social Medicine, in partnership with the City of Toronto and United Way Greater Toronto (UWGT), are creating what is believed to be the firstof-its-kind-in-Canada Social Medicine Supportive Housing site in Parkdale, Toronto. The proposed four-storey modular building at the south parking lot of UHN’s EW Bickle Centre for Complex Continuing Care, will provide 51 people from historically-marginalized groups who are frequent users of hospital services, with accessible, safe, secure and affordable housing. The site is being designed with a unique approach, including strategies to address the social determinants of health – such as housing, food, financial security – and their long-term impacts on individuals’ quality of life. “We know that our most frequent users of hospital services are those without stable, safe housing and are in need of home-based services. Approximately 230 individuals represent over 15,000 visits to UHN’s Emergency Department’s because they don’t have access to better alternatives,” says Dr, Kevin Smith, President & CEO, UHN.

HOMELESSNESS IS ONE OF THE MOST IMPORTANT SOCIAL DETERMINANTS IMPACTING HEALTH OUTCOMES IN OUR CITY AND IN CANADA. AS HISTORICAL INEQUITIES BECAME EVEN MORE EVIDENT DURING THE PANDEMIC, INNOVATIVE INTERVENTIONS ARE URGENTLY NEEDED.

“This first-in-Canada initiative by UHN, made possible through partnerships with the City of Toronto and United Way Greater Toronto, will make a meaningful difference in the lives of those most in need – a need which has been made even more urgent and apparent as a result of the COVID-19 pandemic. We are grateful to the Government of Canada, the Province of Ontario and the City for these needed investments.” The UHN-owned and city-leased site will be ready for occupancy around spring 2022. It will serve those exiting or at risk of homelessness, with a focus on seniors, women, Indigenous Peoples and racialized persons. The support from UHN’s Gattuso Centre for Social Medicine and community partners will allow for integrated supports for residents. They will be connected to a range of services that will consider food security, income

security, mental health, career development and other services to be delivered on site. Residents will also be connected to primary care and other health services. “Homelessness is one of the most important social determinants impacting health outcomes in our city and in Canada. As historical inequities became even more evident during the pandemic, innovative interventions are urgently needed. We are very excited to partner with community organizations, City and United Way Greater Toronto, to launch this project and have it ready to serve the community very soon,” says Dr. Andrew Boozary, Founding Director of the Gattuso Centre for Social Medicine. “The new modular homes with supports planned for 150 Dunn Ave. are so much more than just a place to live. These are homes within a vibrant and welcoming community that will

improve the health and well-being of those who will live there, as well as the surrounding community. Thanks to our strong partnership with the other governments and this very unique partnership with UHN, United Way Greater Toronto and their community partners, we can deliver a new model of care that responds to the unique needs of residents and will make a real difference in their lives. I look forward to opening these new supportive housing units for residents very soon,” says Mayor John Tory. “To lift people out of poverty, communities need affordable housing and access to social services. These homes with supports are a strong example of the social service sector’s role in community health. Government partners have shown incredible leadership with this investment, made even stronger by working with healthcare, community partners and local residents,” says Daniele Zanotti, President & CEO, United Way Greater Toronto. The Social Medicine Supportive Housing project is delivered in partnership with all levels of government. The project has secured, through the City of Toronto, funding from the federal government’s Rapid Housing Initiative, City of Toronto Open Door program incentives and provincial opH erating funding for support services. ■

This article was provided by UHN News.

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NEWS

Concussion calculator predicts recovery time, risk of long-term symptoms don’t know,” is rarely a phrase anyone wants to hear from a doctor. Yet, for the 150,000 Ontarians diagnosed with a concussion each year, it’s often the response they get, if they ask when they’ll start to feel better. The ability to determine who will recover quickly, and who will continue to suffer from symptoms has largely eluded the medical community. Until now. With up to 20 per cent of adults with concussion experiencing symptoms that persist beyond three months post-injury, a team of researchers at the KITE Research Institute at UHN asked: “What risk factors pre-dispose an adult to longterm symptoms?” The findings, which were published in PLOS Medicine, have been translated into a new, online calculator that helps doctors determine which adult

“

patients are at greater risk of experiencing persistent concussion symptoms – and it’s the only one of its kind. “Until now, we’ve had no way of predicting who will bounce back, and who will continue to suffer from migraines, dizziness, and other symptoms that prevent people from fully returning to daily life,” says research analyst Laura Langer, the study’s Lead Author. “Doctors can now use this calculator to identify those at risk for longer symptoms and develop a tailored treatment program for each patient,” says Dr. Mark Bayley, Program Medical Director of Toronto Rehab, and one of the co-authors on the study. The calculator is most impactful when a patient is first diagnosed, and valid for six months, post-injury. While data was collected in Ontario, outcomes can be scalable across Canada and beyond.

WHO IS AT RISK?

By leveraging the ICES Data Repository – a province-wide archive that integrates multiple health databases – the team captured unprecedented, comprehensive, information of Ontarians with concussions, five years preand two years post-injury. They found that groups at highest risk of persistent post-concussion symptoms include: • Adults over 61 years old • Adults with a history of high healthcare utilization in the year prior to injury • Adults with a history of anxiety and/ or depression • Adults with a history of personality and bipolar disorders

HOW THE CALCULATOR WORKS

Once doctors log onto the calculator, they’re prompted to ask patients

five questions relating to their health history. Based on responses, the calculator generates a score that allows doctors to quickly assess a patient’s risk of prolonged recovery. Doctors use this information, at the time a concussion is diagnosed, to create more patient-centred treatment plans. This may include more frequent monitoring, earlier referrals to specialists, a customized exercise prescription and educational materials. The calculator is also useful in reassuring patients with a low-risk score of the likelihood of good outcomes. The study was funded by, and conducted in collaboration with, Ontario Neurotrauma Foundation, with supH port from the UHN Foundation. ■ This article was submitted by UHN News.

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AUGUST 2021 HOSPITAL NEWS 9

NEWS

Neurovascular team performs novel

brain aneurysm procedure By Elizabeth Benner n May, the Neurovascular team at St. Michael’s Hospital of Unity Health Toronto performed the first surgery in North America using a novel stent that may simplify surgical treatments for complex aneurysms and decrease procedural risks for the patient. Dr. Vitor Pereira, a neurosurgeon at St. Michael’s Hospital who specializes in minimally-invasive procedures of brain and spinal cord blood vessels, led the team which included, technologists, nurses, physicians and researchers. “The challenge of treating complex aneurysms is to have a device that is large and long enough to reconstruct the artery,” says Dr. Pereira. “With previous generations of the stent, we might need multiple devices to treat the same case, which increases the complexity and risk of the procedure. This device has also a coating system that decreases the stroke risk for the patient as well.” Throughout our bodies, a branching network of vessels distributes blood to keep us alive. A compromised arterial wall can lead to a ballooning of a vessel which swells with blood, called an aneurysm. Aneurysms can be dangerous, especially in the brain, as they can lead to a stroke if ruptured. A brain aneurysm on a large, irregularly-shaped section of artery is often called a Complex Intracranial Aneurysm. One of the treatments for this condition is to insert an endoluminal stent, a small tube of braided wire often only a few millimeters in diameter, to redirect blood flow out of the aneurysm and allow it to decrease in size. This is done by making a small incision in the artery in the groin and navigating through the blood vessels to the brain using wires and catheters. For more than two years leading up to the surgical procedure, Dr. Vi-

tor Pereira and his research team at the RADIS lab – short for Robotics, Artificial Intelligence, Dynamic Flow, (Advanced) Imaging, and Simulation – performed numerous experiments that helped inform device engineers on how to increase the stent’s efficiency. The stent, ‘Pipeline Vantage’, was manufactured and designed by the medical device company, Medtronic, and went through various improvements such as decreasing the circumference of the wires, improving the deployment system of the stent and incorporating a new surface coating. These changes resulted in an 80 per cent overall improvement compared to the initial prototype. The RADIS Lab is located at the Li Ka Shing Knowledge Institute at Unity Health Toronto. As the name describes, this team of surgeons and scientists specialize in using advanced technology to develop novel treatments in the neurovascular field. They are building a repertoire of groundbreaking accomplishments, including performing the world’s first robotic-assisted brain aneurysm repair in 2019.

“Translating advanced technologies from bench to bedside is what we do best. Before taking any new technology to the procedure room, we perform numerous experiments in the lab to ensure its safety for patients,” says Nicole Cancelliere, Research Program Manager and Radiographer at the RADIS lab. “We are committed to driving innovation to continuously improve the care we can offer our patients. It’s rewarding to see this new stent technology that we helped develop in the lab being used in the clinical space to treat patients and improve outcomes.” This fourth generation stent is not yet approved in the U.S., nor are any other North American neurosurgeons trained in it. The first 50 cases treated with the stent are being performed at locations in Europe and Australia, and St. Michael’s Hospital is the only North American unit that has been given permission by the developer and Health Canada to use the product. “The patient who received the stent had a brain aneurysm which was sending clots to the brain and causing

strokes. We admitted him in an emergency setting and we used the novel stent to reconstruct his complex aneurysm. It was a good application for this new technology.” Dr. Pereira says about the first North American patient to receive the stent. “The MRI that we performed after the surgery showed that the stent was well-positioned and the patient was discharged two days later. We are now waiting for the next follow-up which will be in six months.” A second procedure using the new stent took place in late June and Dr. Pereira will perform a study to compare previous generations of the stent to the most recent version. Once the initial 50 cases have been performed, a training program is aimed to commence this year for physicians looking to learn the new technique. Dr. Pereira says that training can increase the success rate of the procedure and reduce complications. “It’s a pretty rewarding experience being part of the training of physicians and a new technology like this one. I’m passionate about education and training,” he H says. ■

Elizabeth Benner is a communications intern at Unity Health Toronto 10 HOSPITAL NEWS AUGUST 2021

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Identifying unique characteristics of human neurons S

cientists at the Krembil Brain Institute, part of University Health Network (UHN), in collaboration with colleagues at the Centre for Addiction and Mental Health (CAMH), have used precious and rare access to live human cortical tissue to identify functionally important features that make human neurons unique. This experimental work is among the first of its kind on live human neurons and one of the largest studies of the diversity of human cortical pyramidal cells to date. “The goal of this study was to understand what makes human brain cells ‘human,’ and how human neuron circuitry functions as it does,” says Dr. Taufik Valiante, neurosurgeon, scientist at the Krembil Brain Institute at UHN, and co-senior author on the paper. “In our study, we wanted to understand how human pyramidal cells, the major class of neurons in the neocortex, differ between the upper and bottom layers of the neocortex,” says Dr. Shreejoy Tripathy, a scientist with the Krembil Centre for Neuroinformatics at CAMH, and co-senior author on this study. “In particular, we wanted to understand how electrical features of these neurons might support different aspects of cross-layer communication and the generation of brain rhythms,

which are known to be disrupted in brain diseases like epilepsy.” With consent, the team used brain tissue immediately after it had been removed during routine surgery from the brains of patients with epilepsy and tumours. Using state-of-the-art techniques, the team was then able to characterize properties of individual cells within slices of this tissue, including visualizations of their detailed morphologies. “Little is known about the shapes and electrical properties of living adult human neurons because of the rarity of obtaining living human brain tissue, as there are few opportunities other than epilepsy surgery to obtain such recordings,” says Dr. Valiante. To keep the resected tissue alive, it is immediately transferred into the modified cerebrospinal fluid in the operating room then taken directly into the laboratory where it is prepared for experimental characterization. It is rare to study human tissue because accessing human tissue for scientific inquiries requires a tight-knit multidisciplinary community, including patients willing to participate in the studies, ethicists ensuring patient rights and safety, neurosurgeons collecting and delivering samples, and neuroscientists with necessary research facilities to study these tissues. After initial analysis, members of the Krembil Centre for Neuroinformatics used further large-scale data

analysis to identify the properties that distinguished neurons in this cohort from each other. These properties were then compared to those from other centres doing similar work with human brain tissue samples, including the Allen Institute for Brain Sciences in Seattle, Wash. Noted in the team’s findings: • A massive amount of diversity among human neocortical pyramidal cells • Distinct electrophysiological features between neurons located at different layers in the human neocortex • Specific features of deeper layer neurons enabling them to support aspects of across-layer communication and the generation of functionally important brain rhythms The teams also found notable and unexpected differences between their findings and similar experiments in pre-clinical models, which Dr. Tripathy believes is likely reflective of the massive expansion of the human neocortex over mammalian and primate evolution. “These results showcase the notable diversity of human cortical pyramidal neurons, differences between similarly classified human and pre-clinical neurons, and a plausible hypothesis for the generation of human cortical theta rhythms driven by deep layer neurons,” says Dr. Homeira Moradi Chameh, a scientific associate in Dr. Valiante’s

laboratory at Krembil Brain Institute, and lead author on the study. In total, the team was able to characterize over 200 neurons from 61 patients, reflecting the largest dataset of its kind to-date and encapsulating almost a decade’s worth of painstaking work at UHN and the Krembil Brain Institute. “This unique dataset will allow us to build computational models of the distinctly human brain, which will be invaluable for the study of distinctly human neuropathologies,” says Dr. Scott Rich, a postdoctoral research fellow in Dr. Valiante’s laboratory at the Krembil Brain Institute, and co-author on this work. “For instance, the cellular properties driving many of the unique features identified in these neurons are known to be altered in certain types of epilepsy. By implementing these features in computational models, we can study how these alterations affect dynamics at the various spatial scales of the human brain related to epilepsy, and facilitate the translation of these ‘basic science’ findings back to the clinic and potentially into motivations for new avenues in epilepsy research.” “This effort was only possible because of the very large and active epilepsy program at the Krembil Brain Institute at UHN, one of the largest programs of its kind in the world and the largest program of its kind in CanH ada,” says Dr. Valiante. ■

This article was submitted by UHN news. 12 HOSPITAL NEWS AUGUST 2021

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A parent’s guide to preparing a child for COVID-19 vaccination By Elizabeth Benner

aregivers and teens may have questions about the COVID-19 vaccine and wondering if it’s right for

them. Dr. Anne Wormsbecker, a pediatrician at Unity Health Toronto based at St. Michael’s Hospital and current interim chief of pediatrics at St. Joseph’s Health Centre, is a good person to turn to for insight. As a researcher, she has examined data on the pneumococcal and chicken pox vaccines. She helped guide the Ontario government on immunization science as a medical epidemiologist at Public Health Ontario. And as a parent and pediatrician, Dr. Wormsbecker is aware of the challenges and concerns which may arise when vaccinating this age group. As a researcher, what drew you to vaccines as a special area of interest? When I moved to Ontario for residency in 2004, it was the same year that more vaccines [for children and toddlers] were rolled out in Ontario, one of which was chicken pox. In my early years in residency, we would still see babies and toddlers hospitalized with complications of chicken pox or even older kids with very severe complications. But towards the end of my training, it was almost unheard of to have kids admitted to hospital with these complications of chicken pox and I found that so inspiring. I think that’s what drew me to look at immunization programs at a population level and look at their impact. The opportunity to share that knowledge broadly was also exciting to me – the idea of an intervention that is available on a large scale to everybody, changing the trajectory of children’s health.

IT IS EXTREMELY RARE TO HAVE A MEDICAL CONDITION THAT IS CONTRADICTION TO THE COVID-19 VACCINE. IT IS RECOMMENDED TO WAIT TWO WEEKS AFTER GETTING ANOTHER VACCINE TO GET COVID-19 VACCINE. What was your reaction when you heard the Ontario government is expanding vaccinations to young people between 12-17? I was really excited to hear this! As a pediatrician, I know that kids have suffered from what has been labelled the ‘parallel pandemic’ of mental health challenges related to prolonged school closures. I’m hoping that by vaccinating children and youth, we can get kids back to school and back to their regular activities as soon as possible. Why is it important to vaccinate kids? The main reason to get kids vaccinated is to get them back to school and back to their regular activities. We do know with this third wave of the pandemic, younger individuals are becoming sicker with COVID-19, so it does offer some individual protection to the children and youth who are vaccinated. Also by vaccinating those 12 and above, we help to get to a state of community protection, or herd immunity, by getting a large proportion of the population immune so transmission is reduced. Are there any reasons for why a young person shouldn’t get the vaccine yet, for example pre-existing conditions? The vast majority of children and youth can get the COVID-19 vaccine. It is extremely rare to have a medical condition that is contradiction to the

COVID-19 vaccine. It is recommended to wait two weeks after getting another vaccine to get COVID-19 vaccine. Also, we don’t give immunizations if you’re sick. So if you have a fever and you’re staying home in bed because you’re sick, that’s not the time to get a vaccine. I really encourage parents and kids to speak with their healthcare providers to ask questions about their own personal health situations. What can parents expect when their child is vaccinated? Parents can expect very similar side effects to those they have seen if they themselves have been vaccinated against COVID-19 or if they recall their child getting an influenza vaccine or perhaps their grade seven vaccines. Certainly the arm where the vaccine was injected will be sore – that’s a good thing! It means your body is mounting an immune response. As well you can feel as if you worked out. So, you might be really tired, have sore muscles – sore legs, arms and other places on your body. Some people might feel as if they have a flu-like illness and want to rest more and have a fever. I learned from a St. Joseph’s colleague who had read US Centers for Disease Control advice to get your vaccine in your dominant arm rather than your non-dominant arm because you move it and use it more, you may have less pain because you’ve kept it active and your circulation has distributed the immune response throughout your

body rather than just in the muscle. If a young person is reading this who wants to be vaccinated but has a vaccine-hesitant caregiver, how should they navigate that situation? These kids can be vaccinated! In Ontario, the law very clearly states there is no formal age of health-care consent. As long as you are understanding of the information provided to you and able to weigh the pros and cons of a decision you are able to provide consent regardless of your age. It’s important for children and youth to know [about consent], always. No matter the health care decisions you’re making: If you understand the benefits of a treatment, the drawbacks of a treatment and the risks of not being treated, you’re able to consent. Is there anything else that you think is important for parents to know? It’s really important not to dismiss kids’ anxiety prior to getting a needle. For me, the COVID-19 vaccine injection was not painful at all. However, some people really feel uncomfortable getting vaccines. We are so fortunate that we have numerous strategies to help manage pain and I would never want pain to be a reason for someone to avoid getting a COVID-19 vaccine. If your child is nervous about getting vaccinated, you can access online resources or use some mindfulness strategies to prepare for immunization. Other ways to make the experience more positive include placement of a numbing cream beforehand, distractions, deep breathing, listening to music while getting your vaccine – the list goes on. I can’t stress enough the importance of providing a patient-friendly vaccine environment considering children and youth may feel some discomfort around the vaccine experience. If your child has special health H care ■

Elizabeth Benner is a communications intern at Unity Health Toronto 14 HOSPITAL NEWS AUGUST 2021

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Mobile

interpretation devices at COVID-19 vaccination clinics

The mobile interpretation devices connect patients to live, medically trained interpreters who offer virtual services in over 240 languages.

By Rachel Galligan ancouver Coastal Health (VCH) has launched 12 mobile interpretation devices at its COVID-19 vaccination clinics to offer broader interpretation service options to residents. Within seconds, the devices connect patients to live, medically trained interpreters who offer virtual services in over 240 spoken languages. To date, the mobile devices have facilitated over 18,000 minutes of live interpretation across VCH COVID-19 vaccination clinics, while the top languages requested include Cantonese (42 per cent), Mandarin (39 per cent), Vietnamese (4 per cent), Farsi and Korean (3 per cent). This service augments in-person translation

support offered by multilingual VCH staff members, community partners and volunteers who work across all vaccination clinics, in addition to formal in-person and pre-scheduled virtual interpretation services, as well as on-demand phone interpreting services offered by Provincial Language Services through the Provincial Health Services Authority. Seventy-four additional devices will be implemented across the VCH region through 2021 to further support patients on their health care journey. “Vancouver Coastal Health serves a diverse, multicultural population. It is our responsibility to ensure patients and clients can easily engage with their health care provider and access

Rachel Galligan is the Communications Leader at Vancouver Coastal Health.

the information they need regarding their treatment and care, says Megan Stowe, executive director of Virtual Health and Clinical Informatics at VCH. “While the pandemic has presented significant challenges to the health care system, it also pushed us to innovate, as we rapidly responded to our communities’ evolving needs. We look forward to expanding the availability of interpretation devices to communities across the region to further improve patient experience and health care outcomes.”

A philanthropic donation made to VGH & UBC Hospital Foundation in 2019 enabled VCH to conduct a pilot project of the mobile interpretation devices across multiple acute and community care sites in the Vancouver region; donations from Richmond Hospital Foundation and Lions Gate Hospital Foundation also funded local pilots, enabling 18 sites to collect data to inform a regional best practice. Use of the devices were found to positively impact patient engagement with care H and health care outcomes. ■

PAEDIATRICS

Are the kids ok? The impact of COVID-19

Mobilizing a path forward for Canada’s children and youth By Emily Gruenwoldt hile many jurisdictions across this country begin to feel a fresh sense of hope, for Canada’s eight million children and youth, the COVID pandemic is far from over. Strict public health measures, necessary to curb transmission of a deadly and highly contagious virus, have taken their toll, and children and youth did not escape unscathed. In fact, children, youth, and their families were impacted disproportionately as schools across the country shuttered, recreational activities, camps, and clubs mostly closed, and many families suffered economic hardship as the result of temporary or permanent job loss. The consequences of prolonged disruptions in routine, community, social, and health services that are emerging now should be a concern to all Canadians, including our elected officials as they map out this country’s path forward. In polling conducted by Abacus Data (May 2021), parents reported major concerns for their children’s mental health and wellbeing as the result of prolonged social isolation. Sixty-two (62) per cent of parents noted deterioration of existing mental health disorders, but 48 per cent also reported the pandemic has created new mental health concerns for their children. At the same time, Children’s Healthcare Canada members (children’s hospitals, community hospitals and children’s rehabilitation centres) are seeing evidence of the toll the pandemic is taking on the young patients they care for. Emergency department visits related to suicidal ideation, eating disorders, substance use, anxiety and non-accidental injuries are increasing across the country. Canadians imagine a better future for their children, and for this

researchers, community and health service providers, policy leaders, and educators to co-create an integrated set of priorities for systemic change, in order to measurably improve the health and well-being of Canada’s children, youth and families. In short, these five interlinked priorities include:

16 HOSPITAL NEWS AUGUST 2021

COMPREHENSIVE, CROSS-DISCIPLINARY RESEARCH

Adopting a life cycle approach to understanding health and well-being from pre-conception through to later life, embracing an equity lens to consider and evaluate unique circumstances of at-risk and marginalized populations.

MOBILIZED COMMUNITIES

Emily Gruenwoldt is President & CEO, Children’s Healthcare Canada; and Executive Director, Pediatric Chairs of Canada.

EMERGENCY DEPARTMENT VISITS RELATED TO SUICIDAL IDEATION, EATING DISORDERS, SUBSTANCE USE, ANXIETY AND NONACCIDENTAL INJURIES ARE INCREASING ACROSS THE COUNTRY. reason children’s advocates have been calling for a pandemic recovery plan that prioritizes Canada’s youth and their families. Inspiring Healthy Futures – a collaborative initiative led by Children’s Healthcare Cana-

da, the Pediatric Chairs of Canada, UNICEF Canada and the Canadian Institutes of Health Research – Institute of Human Development, Child and Youth Health engaged over 1,500 youth, family partners,

Children, youth and families must be connected around issues that matter, where their lived experience is fully valued and included in research, policy decisions and community action. Infrastructure to amplify peer support opportunities, promote opportunities for youth engagement and participation, and build capacity for youth led change and advocacy is critical.

ACCESSIBLE, ADAPTABLE HEALTH AND WELL-BEING SYSTEMS:

All children, youth and families should have timely access to an integrated, family-centred system of physical and mental health services and benefits, flexible to each family’s needs. Integrated health and social service records, accessible to parents and health service providers would support a more wholistic approach to care for children. More systemically, Canada requires a consistent and www.hospitalnews.com

PAEDIATRICS comprehensive data set – comparable across jurisdictions and linked to education – to measure children’s health, healthcare, and health outcomes.

SCHOOLS AND COMMUNITIES AS HEALTH AND WELLBEING HUBS

Schools and communities must evolve to be dynamic hubs to connect parents, child and youth to the resources, outdoor, social, and recreational spaces kids need to thrive. Every child should have access to child care, quality early learning, developmental and social care, and necessary diagnoses, therapy, and early interventions, where parents and caregivers are fully engaged as partners and peer supports.

CHILD CENTRED POLICIES AND STRUCTURES

Canada must increase the will and capacity of governments at every lev-

el to incorporate child-friendly decision-making protocols and practices. This means coordinating policies across federal, provincial, and territorial jurisdictions, incorporating child

impact assessments, and improving data and outcomes monitoring. It also means establishing a non-partisan federal accountability office for children and youth, guided by their voices, and

fully respecting and advancing the rights and self-determination of First Nations, Métis and Inuit children and youth. The COVID 19 pandemic has provided an unmissable opportunity to act: to act on behalf of Canada’s children and youth to rewrite the rules for the policy, investment, innovation, and partnerships needed for kids to thrive. It means working together in new, unrelenting ways to create a more integrated and decolonized system of health, social services, and social protection. Inspiring Healthy Futures is a launching point for mobilizing our path forward, harnessing the energy, commitment, and resources of a community – a country – passionate about our eight million children and youth. It’s a vision and commitment whose time has come. Learn more about the Children’s Healthcare Canada at childrenshealthcarecanada.ca and the Inspiring Healthy Futures initiative at inH spiringhealthyfutures.ca. ■

Emily Gruenwoldt is President & CEO, Children’s Healthcare Canada; and Executive Director, Pediatric Chairs of Canada.

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AUGUST 2021 HOSPITAL NEWS 17

PAEDIATRICS

Building inspiring healthy futures: A partnership for children, youth and families in Canada By Sarah A De La Rue he community of purpose convened through Inspiring Healthy Futures has developed an exciting and unique vision to measurably improve the health and well-being of children, youth and families in Canada as discussed in the article on page 16 of this issue. This collective strategy comprises five interlinked domains that are the foundation for a healthier, brighter future for children, youth and families in Canada through the generation of systemic change. The domains include both advocacy and action to mobilize and connect communities around cross-disciplinary research with an equity lens, enhance access to integrated healthcare, social services and education, and incorporate a child-centred approach to policy and structures. The vision has already demonstrated a strong resonance with the organizations and individuals engaged in its development, as well as with a broad cross-section of the public who were engaged in a subsequent public awareness campaign. However, for this vision to be achieved – to “rewrite the rules for policy, investment, innovation and partnerships needed for children, youth and families in Canada to thrive” – it is essential that we maintain this momentum, to drive the impact and fully unlock the potential. Key to this will be harnessing the collective passion of the organizations and individuals who contributed to the development of the vision into a common purpose connected by a shared identity. This community of purpose has already embodied one of the primary elements essential to establishing a common purpose, with extensive engagement of children, youth and families allowing their viewpoints and needs to form the core of the vision. Moving forward it will be essential to keep all these organizations and individuals connected

and aligned through shared conversations and activities, as well as grow our partnership. We can achieve this by building on the strengths and priorities of all those in Canada who share this passion for the health and well-being of our children, youth and families. Using a collective impact model, Inspiring Healthy Futures is now taking the next step that will allow this multi-sector community of purpose to deliver its vision. The organizations that founded Inspiring Healthy Futures (UNICEF Canada, Children’s Healthcare Canada, the CIHR Institute of Human Development, Child and Youth Health, and the Pediatric Chairs of Canada) are demonstrating their ongoing commitment through the establishment of a backbone team that will form, nurture and grow a partnership with a focus that is dedi-

cated to maximizing the impact of the Inspiring Health Futures vision. This backbone team’s primary focus will be to support alignment with and delivery of the vision to engender development, harmonization and growth of multi-sector activities. Incorporating and continuously updating the perspective on the needs of children, youth and families will support constant and focused co-creation along the pathway to delivering on the Inspiring Healthy Futures vision. The partnership will also co-create and communicate metrics that will allow both the sharing of, but also learning from and building upon, the successes of the partnership. Comparison of efforts across the partnership and beyond will drive breakthroughs that will enhance everyone’s activities, allowing shifts in perspective and approach that will benefit all. Demon-

strating these successes, including both impact and return on investment, will support identity and connection across the partnership, key elements to sustaining momentum and attracting necessary funding. Through these actions, we will ensure that a vision that found it’s momentum and resonance during a pandemic – a time of unprecedented instability and, for many, crisis – will be supported by a community of purpose that will sustain velocity towards a healthier, brighter future for our children, youth and families in Canada. We invite you and everyone who shares this passion to engage with us, consider joining our partnership and reach out to share your priorities and concerns, to discuss where you hear yourself and your organization within this vision, and to co-create our pathH way to impact. ■

Sarah A De La Rue is Executive Director, Inspiring Healthy Futures. 18 HOSPITAL NEWS AUGUST 2021

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The impact of COVID-19 By Jessamine Luck hile the COVID-19 pandemic has occurred in a series of waves, the heightened levels of depression and anxiety among children and youth seen at the start of the pandemic have remained consistent. This is one of many new preliminary findings from the ongoing COVID-19 mental health study led by The Hospital for Sick Children (SickKids). Taken together, the latest findings demonstrate a serious, sustained negative impact on the mental health of Ontario children, youth and their families. The study currently has over 2,700 participants, ranging in age from two to 18, who live in Ontario. It is led by four research teams, each with their own areas of expertise in child and youth health. The research teams surveyed different participants at different time points to get a holistic understanding of how public health measures, including school closures,

20 HOSPITAL NEWS AUGUST 2021

have impacted child and youth mental health and well-being.

LOSS OF IN-PERSON SCHOOL HAD SIGNIFICANT IMPACT ON CHILD AND YOUTH MENTAL HEALTH

The research team’s initial findings show mental health did not improve as the school year progressed, building on their previous findings that a majority of children and youth reported worsening mental health during the initial COVID-19 lockdowns in 2020. Across participants with and without pre-pandemic mental health diagnoses, more than half of 758 children aged eight to 12 years old and 70 per cent of 520 adolescents aged 13 to 18 years old reported clinically significant depressive symptoms during the second wave (February to March 2021). Among 1,494 participants, the researchers observed a strong association between time spent on online learning

and depression and anxiety in schoolage children (six to 18 years old). The more time students spent on online learning, the more symptoms of depression and anxiety they experienced. Before the pandemic, 58 per cent of 1,261 participants surveyed participated in school sports and/or other extracurriculars, activities that are known to boost physical and mental health. During the pandemic, only 27 per cent participated in sports and 16 per cent in extracurriculars. Furthermore, losing in-school services, such as counselling, speech/language and occupational therapy, and learning supports, resulted in worse mental health outcomes for children and youth. “School represents more than just academics for children and youth. For many, school and its in-person interactions and activities form the cornerstone of their lives,” says Dr. Daphne Korczak, Principal Investigator of the study and Child and Adolescent Psy-

chiatrist at SickKids. “Our initial findings show that despite periods of modified, in-person school, mental health measures did not improve significantly, including for those who attended school in person. This should serve as an urgent call to ensure that we do not replicate school as it was this past year in Ontario, and we get kids back to in-person learning, activities, and sports.”

MENTAL HEALTH IMPACTED BY INEQUITIES, INCREASED SCREEN TIME DURING COVID-19

The initial findings suggest that families who were already vulnerable before the pandemic, for example, those with lower household income and parental education rates, were disproportionately impacted by economic hardship as a result of the pandemic, such as job loss and food insecurity. www.hospitalnews.com

PAEDIATRICS These families experienced higher levels of both child and caregiver mental health symptoms and stress. For all families, caregiver mental health and family functioning were impacted by their children’s mental health difficulties and vice versa. Increased time on screens had a wide-ranging impact on the mental health of children and youth as well. Across 2,206 participants of all ages, increased time spent watching TV, on digital media and video games was associated with more irritability, hyperactivity, inattention, depression and anxiety. In a separate but related study published in the Canadian Journal of Public Health on July 8, 2021, TARGet Kids! researchers found the public health measures implemented in Ontario between April 14 to July 15, 2020, were associated with a decrease in outdoor time and an increase in screen time among young children under 10 years of age. The study also found this association was stronger in females com-

OUR DATA OVERWHELMINGLY POINT TO THE SIGNIFICANT AND SUSTAINED MENTAL HEALTH EFFECTS THAT THE PUBLIC HEALTH MITIGATION STRATEGIES AND SCHOOL CLOSURES HAVE HAD ON CHILDREN, YOUTH AND THEIR FAMILIES pared to males, and children aged five years old and above compared to children under the age of five. “This study contributes to the growing evidence that the pandemic is associated with unhealthy movement behaviours among children,” says Dr. Catherine Birken, Principal Investigator of the TARGet Kids! study, co-investigator of the COVID-19 mental health study, Staff Paediatrician and Senior Scientist in the Child Health Evaluative Sciences program at SickKids. “We need to invest in safe outdoor opportunities in child-centred settings, such as schools and public parks. Furthermore, restarting camps,

activities and sports will be crucial to support families in reducing screen time and promote children’s social and emotional development.”

THE BOTTOM LINE: KIDS NEED SCHOOL, FRIENDS AND FUN

The preliminary findings from the ongoing COVID-19 mental health study have not yet been peer-reviewed but the research team intends to publish a number of different articles containing the recent data. The research team says that by sharing preliminary findings now, they hope to provide policy-makers, public

health agencies and others with the information they need when considering decisions that will impact children and youth in Ontario. “Our data overwhelmingly point to the significant and sustained mental health effects that the public health mitigation strategies and school closures have had on children, youth and their families in Ontario,” says Korczak, who is also an Associate Scientist in the Neurosciences & Mental Health program at SickKids and an Associate Professor in the Department of Psychiatry at the University of Toronto. “Kids need school, they need their friends and they need to have fun. As our focus shifts to reopening society, we must have meaningful conversations about prioritizing the needs of our children H and youth.” ■ Some findings are not yet peer-reviewed; point to urgent need to prioritize child and youth mental and physical health during the COVID-19 pandemic and beyond.

Jessamine Luck works in communications at The Hospital for Sick Children (SickKids).

Continuing to Stand by Sick Children Every day, thousands of sick and injured kids visit children’s hospitals across Canada. Six-year-old Darcey is one of them. She visits Children’s Hospital in London every three weeks for a life-sustaining infusion for her atypical Hemolytic Uremic Syndrome, an ultra-rare genetic blood disorder.

KIDS AT CHILDREN’S HOSPITAL STILL NEED YOU.

“It’s scary to need the hospital for your child during the global pandemic,” says her mom, Dionne Papineau. “Since Darcey is immunosuppressed, she’s at greater risk for complications from COVID-19.” Although the pandemic has impacted adult health care substantially, that doesn’t mean paediatrics is in the clear. Children’s Hospital in London has experienced a significant impact to care delivery, causing consequential delays and cancellations. Our kids’ health is at stake. Children’s Health Foundation is inviting Western Ontario to support its Stand By Me campaign in support of kids with serious health issues. Donations will invest in reinforcing and strengthening the care at Children’s Hospital to ensure it remains at its strongest, today and in the future.

Learn more about the campaign and donate at

www.childhealth.ca/standbyme www.hospitalnews.com

AUGUST 2021 HOSPITAL NEWS 21

PAEDIATRICS

Improving vaccine confidence through better pain management for children and their families OVID-19 vaccines have already been approved for adolescents, and efforts are underway to approve COVID-19 vaccines for children under 12 years of age. To support increased vaccine confidence and uptake, immunizers and healthcare professionals can become familiar with strategies for managing immunization pain and needle fear. Studies tell us that fear of needles is the primary reason why seven per cent of adults and eight per cent of children avoid immunizations. Poorly managed needle pain and discomfort contributes to the development of needle fears as well as avoidance of vaccines and healthcare later in life. Mass vaccination against COVID-19 poses a unique opportunity to ensure a generation of children grows up with less fear of needles and immunizations, as well as more confidence in the health system. Thankfully, science-backed strategies exist to address these challenges. Solutions for Kids in Pain (SKIP) is a knowledge mobilization network on a mission to improve children’s pain management by mobilizing evidence-based solutions, including strategies to mitigate needle fear and pain as contributing factors to vaccine hesitancy. “Our kids have long had strong needle fears… they would scream as we walked from the car to the office, hide behind chairs in the doctor’s office, and multiple staff would hold them down,” says Megan MacNeil, parent and SKIP Knowledge Broker. “I was doing my best with what I knew, but when I became a SKIP team member, I realized that getting our COVID-19 vaccines was the perfect opportunity to take a completely different approach.” Creating a positive vaccination experience starts with developing a plan with the child being immunized. The CARD (Comfort Ask Relax Distract) System is an excellent resource in this area. Immunizers should inform children about what to expect and allow them to make decisions to make them

feel empowered with both information and appropriate choice. “CARD gave us a simple way to break down the steps to make the needle more manageable. It made all the difference to plan ahead with our kids, and to take it slow. We listened to music on the way there, took a few minutes of deep breathing before going in, and spent the entire appointment watching videos and chatting about treats we planned to pick up afterwards,” Megan adds. Before the immunization, talk with the child to determine their preferences. Discuss with the child about whether they would like to sit up, either alone or on their parent’s lap, or if they would like to recline (this can be helpful for those who have a history of fainting with needles). No one should hold down the child during the procedure. Ask children what type of distraction they prefer, such as watching a funny video or listening to music. Distraction should be used leading up to, during, and following the immuniza-

tion. Having the child blow bubbles or a pinwheel while being immunized can also encourage deep breathing. Immunizers should also partner with parents to discuss options. For infants, breastfeeding a few minutes before and during the immunization is encouraged to reduce vaccination pain. If the infant is not breastfeeding, a small amount of sugar water given before the needle can also reduce pain and distress. Numbing cream (topical anesthetic) can be used effectively in combination with any of the strategies described above for both infants and children alike. It should be applied 2060 minutes prior to the immunization, depending on the product. Research urges parents and immunizers to avoid common reassurances such as “It will be over soon” or “You will be fine” before or during an immunization. Rather, positive verbal affirmations are helpful. Letting the child know specifically what they did well (staying still, breathing deeply, etc.)

after the immunization also helps to ensure vaccines go well in the future. If children have severe needle fears (also called needle phobia), additional support from a mental health professional may be needed. Treatments such as cognitive-behavioural therapy, in combination with pain management strategies, are supported by research to effectively treat severe needle fears for a positive immunization experience. Developing a plan in consultation with the child and using simple, straightforward strategies for pain management helps children develop a sense of agency and builds trust between healthcare professionals and families. SKIP’s vision is to build healthier Canadians through better pain management for children. SKIP brings together Canada’s world-renowned pediatric pain research community, front-line knowledge user organizations and end beneficiaries. Visit www. kidsinpain.ca for more information or H follow us @kidsinpain. ■

This article was provided by SKIP. 22 HOSPITAL NEWS AUGUST 2021

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PAEDIATRICS

The Paediatric Inpatient Research Network he Paediatric Inpatient Research Network (PIRN) is led by chair Dr. Sanjay Mahant and vice-chair Dr. Peter Gill, both Paediatricians and Associate Scientists at the Hospital for Sick Children, and Carol Chan, Network Coordinator and Research Project Manager at the Hospital for Sick Chidlren. PIRN was launched on July 23, 2019 at an inaugural meeting in Toronto. This meeting was funded by the Ontario Child Health Support Unit (OCHSU) and brought together Paediatric Medicine hospital research leads from all major children’s academic centres, large community hospitals, researchers, clinicians, and parent partners. It was at this inaugural meeting that PIRN developed its mission and vision, national team, and network partners. PIRN has subsequently also formed an Executive Council composed of the chair, vice-chair and six other

PIRN’S OVERARCHING MISSION IS TO WORK WITH CHILDREN AND FAMILIES TO GENERATE EVIDENCE THAT IMPROVES CARE AND OUTCOMES FOR HOSPITALIZED CHILDREN IN GENERAL PAEDIATRIC SETTINGS. executive members. The executive members champion portfolios (annual meeting/membership, community, education, mentorship, and research activities) and set milestones and deliverables for each portfolio. PIRN’s overarching mission is to work with children and families to generate evidence that improves care and outcomes for hospitalized children in general paediatric settings. PIRN is composed of members from all major children’s academic centres from Newfoundland to British Columbia and several large community hospitals. PIRN includes

experts with diverse backgrounds who work in the field of general paediatrics and is an inaugural Children Health Canada’s Child Health Hubs. PIRN has also developed partnerships with key stakeholders, including the Canadian Paediatric Society, the Canadian Association of Paediatric Nursing, the Maternal Infant Child and Youth Research Network, and Patient Family Advisory Groups at several hospitals. PIRN focuses on conditions which are prevalent and cumulatively expensive in paediatric hospital care, such as common respiratory illnesses (e.g.

bronchiolitis, asthma, pneumonia) and infections (e.g. orbital cellulitis). In this regard, six Ontario PIRN sites, led by Dr. Sanjay Mahant, completed a CIHR-funded pragmatic bronchiolitis randomized controlled trial (RCT) comparing intermittent vs. continuous pulse oximetry for hospitalized infants with bronchiolitis. The study results were published in JAMA Pediatrics in March 2021. The study enrolled 229 infants hospitalized with stabilized bronchiolitis with and without supplemental oxygen and with care managed using an oxygen saturation target of 90 per cent. The study concluded that intermittent (every four hours) pulse oximetry monitoring of infants with bronchiolitis results in similar outcomes to continuous pulse oximetry monitoring and recommends that intermittent pulse oximetry should be routinely used in stabilized infants. Continued on page 24

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AUGUST 2021 HOSPITAL NEWS 23

PAEDIATRICS

Youth are finding ways to be resilient during pandemic By Suelan Toye new study led by researchers at Holland Bloorview Kids Rehabilitation Hospital is shedding light on how youth, both living with and without disabilities, are finding ways to cope during the COVID19 pandemic – and improve their mental health. “Although much attention has been given to pandemic-related mental health challenges that youth have faced, we don’t know much about the coping mechanisms youth and young adults have used and how this is different for youth living with and without disabilities,” says Dr. Sally Lindsay, a senior scientist at the Bloorview Research Institute (BRI) and lead of the institute’s TRAIL Lab (Transitions And Inclusive Environments Lab). Indeed, studies have shown that the psychosocial impact of COVID-19 has disproportionately affected adolescents and young adults’ mental health

due to the changes they have encountered during the pandemic. These changes include remote schooling, limited in-person activities and disruptions to their daily routines. Dr. Lindsay, an associate professor at University of Toronto’s Department of Occupational Science & Occupational Therapy, and her research team conducted online qualitative interviews with 34 young adults (16 to 29 years) living in the Greater Toronto Area last July to November, then one of Canada’s COVID19 ‘hot zones’. The study’s co-authors are Hiba Ahmed and Demitra Apostolopoulos, both researchers at the BRI’s TRAIL Lab. Through primarily Zoom in-depth interviews, the research team asked youth, half who were living with a disability, in part, how they were coping with the pandemic in their daily lives. The team found that the young adults could lean on their families for

Dr. Sally Lindsay is a senior scientist at the Bloorview Research Institute (BRI). social support and access government sources for financial assistance. Many kept themselves busy by looking for volunteering and job opportunities, while others took on extra courses as summer jobs were cancelled due to pandemic public health restrictions. The majority of the youth surveyed also expressed that although they encountered some challenges, there were benefits to working or going to school remotely. This was especially true for youth with disabilities who found that arranging accessible transit was often very difficult. Additionally, for many youth, getting outdoor exercise was also a big boost to their mental health and wellbeing as well. However, there were some stark differences in the amount and variety of supports and activities between young

The Paediatric Inpatient Research Network Continued from page 23 An additional focus of PIRN is the priority setting of research topics in Canadian Paediatric Hospital Care. Led by Dr. Peter Gill and funded by CIHR, PIRN is partnering with clinicians and families to conduct a James Lind Alliance (JLA) Priority Setting Partnership (PSP). The goal of the partnership is to identify and prioritize unanswered questions around the treatment and care of children in general paediatric inpatient units (GPIU). The project is being overseen by a steering group comprised of patients, carers, youth, paediatricians, and nurses. This fall, we will have identified the top 10 unThis article was submitted by PIRN. 24 HOSPITAL NEWS AUGUST 2021

answered questions on paediatric hospital care which will be used to guide future patient-oriented research projects. In addition, Dr. Peter Gill and Dr. Sanjay Mahant are leading a project funded by the Physician Services Incorporated (PSI) Foundation using health administrative data available at IC/ES to describe the prevalence, cost, and variation in cost of paediatric hospitalization by condition in children in Ontario. Findings from these two projects will be important to help prioritize research topics for researchers and research funding agencies, and can be used to prioritize quality

improvement efforts in hospitals and the healthcare system. Ultimately, the goal of this project is to direct research efforts to areas of high priority to build a stronger evidence-base, to improve outcomes of hospitalized children, and optimize the performance of the H healthcare system. ■ For more information about PIRN please visit www.pirncanada.com If you have any questions or comments please email us at contact.pirncanada@ sickkids.ca You can also follow us on Twitter for the latest updates at https://twitter.com/ CanadaPirn

adults living with various disabilities and those without a disability. For instance, youth with disabilities didn’t have as many job or volunteer opportunities and had fewer social and financial supports. They also did not venture outside as much as youth without disabilities. “Before the pandemic, youth with disabilities were more often under-employed than those who didn’t have a disability. The pandemic has just exacerbated their situation,” says Dr. Lindsay. “These findings show how we as a society need to do better to support our youth living with disabilities.” Dr. Lindsay recommends that youth living with disabilities need support in how to identify work or volunteer opportunities that they can participate in, including options to work remotely from home. Providing more accessible outdoor spaces would help these teens and young adults venture outside more frequently as well. This study is part of a larger project from the TRAIL Lab called the Health and Productive Paid Work for Youth with Disabilities (HAPPY) project – a study that focuses on enhancing inclusive employment for youth with disabilities. Thanks to the Kimel Family Opportunities Fund and a CIHR-SSHRC Partnership Grant (Canadian Institutes of Health Research-Social Sciences and Humanities Research Council) for their support in the study published online in May 2021 in the H Disability and Health Journal. ■ Suelan Toye works in communications at Holland Bloorview Kids Rehabilitation Hospital. www.hospitalnews.com

PAEDIATRICS

New study to monitor COVID-19 illness and vaccine safety, effectiveness in children and youth in Canada pan-Canadian study that’s monitoring the effects of COVID-19 and the safety and efficacy of COVID-19 vaccines in Canadian children and adolescents started June 1. The Government of Canada is supporting the study through its COVID-19 Immunity Task Force and Vaccine Surveillance Reference Group. “Vaccines being administered to protect against COVID-19 have gone through rigorous safety and efficacy evaluations in all eligible age groups,” says Dr. Manish Sadarangani, co-principal investigator of Canada’s Immunization Monitoring Program ACTive (IMPACT) network, which is conducting the study, and the site investigator for B.C. “Continued surveillance for any vaccine is always an important component of ensuring continued

safety and effectiveness for the general population.” The study will monitor pediatric hospital visits to identify those that may be associated with a COVID-19 infection or vaccination. The IMPACT network will monitor the symptoms and reactions of any children or adolescents admitted to the hospital due to COVID-19, including for multisystem inflammatory syndrome, and will track the continued safety and effectiveness of COVID-19 vaccines. “As COVID-19 vaccines are rolled out to those aged 12 to 17 and potentially younger children in the near future, we will analyze whether vaccination is associated with fewer children and youth being admitted to hospital with COVID-19 and fewer severe cases of the disease,” says Dr. Julie Bettinger, an investigator at BC Chil-

dren’s Hospital and the IMPACT data center director and epidemiologist. The IMPACT network has continuously monitored a variety of pediatric vaccines for more than 30 years. Its efforts will help inform public health and medical experts of unusual post-vaccine events. The network is well-positioned to evaluate the impact of vaccination programs in cases of COVID-19 in children and youth who are in hospital. This latest study will build upon information gathered by the research team’s Canadian Paediatric Surveillance Program COVID-19 Study, which collected data from the beginning of the pandemic until the end of May 2021, to provide a more complete understanding of how COVID-19 affects children and youth. “This study will bring together information from hospital across Cana-

da so that we can quickly identify and respond to any emerging patterns that could be related to COVID-19 vaccination,” says Dr. Sadarangani, an investigator and director of the Vaccine Evaluation Centre at BC Children’s Hospital. “These studies on the effects of illness from COVID-19 and COVID-19 vaccine safety and effectiveness will help us learn more about the best ways to protect younger Canadians and their families,” says Canada’s chief public health officer Dr. Theresa Tam. “Monitoring safety and effectiveness of COVID-19 vaccines in this population will also contribute to optimal COVID-19 prevention and control, population-wide.”Regardless, as always, we need to continue monitoring the situation based on our specific Canadian context to ensure Canadian H children and youth remain safe.”■

This article was provided by BC Children’s Hospital.

www.hospitalnews.com

AUGUST 2021 HOSPITAL NEWS 25

LONG-TERM CARE NEWS

Seniors DANCE program waltzes across Canada hroughout her retirement, Joanne Weeks always stayed active and attended weekly fitness classes. But when the pandemic hit, the classes were cancelled. Weeks noticed the decline not just in her fitness level, but her balance and flexibility as well. “I felt like my fitness had gone backwards,” she says. “Things that had always been easy for me, like going upstairs and gardening, became harder. I was at a loss without my fitness classes.” Then, a friend of Weeks’ posted on Facebook about some virtual fitness and dance classes.

VIRTUAL FITNESS FOR OLDER ADULTS Joanne Weeks

In response to the pandemic, the GERAS Centre for Aging Research (GERAS Centre), a joint research centre of Hamilton Health Scienc-

GERAS DANCE HAS BEEN FILLING A NEED FOR OLDER ADULTS NOT JUST PHYSICALLY, BUT SOCIALLY AND MENTALLY

es (HHS) and McMaster University, partnered with the YMCA of Hamilton/Burlington/Brantford to create LiveWell at Home, a virtual senior-friendly fitness program. “I was one of the first people to register for the virtual fitness program,” says Weeks. “It was exactly what I needed to get back what I’d lost.” For the past three years, the GERAS DANCE research study has involved more than 500 seniors at 12 YMCA sites across Ontario. The study has found that dance classes for older adults

sharpens the mind, strengthens the body and helps build social connections. “GERAS DANCE has been filling a need for older adults not just physically, but socially and mentally,” says Dr. Alexandra Papaioannou, Geriatrician at HHS and executive director at the GERAS Centre.

STAYING SOCIAL AND ACTIVE DURING THE PANDEMIC

“The pandemic made it difficult for some older adults to get out and

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LONG-TERM CARE NEWS many become housebound,” says Dr. Patricia Hewston, co-creator of the GERAS DANCE program and post-doctoral fellow at McMaster University’s Labarge Centre for Mobility in Aging. “By developing GERAS DANCE into a virtual program, it allowed older adults to stay connected while improving their health,” says Dr Patricia Hewston. GERAS DANCE is one of three fitness classes offered in the LiveWell at Home virtual fitness program. The program began in January 2021 and is ongoing. Weeks really enjoyed the GERAS DANCE classes. Each class built on the last one and allowed for modifications based on the participants’ comfort level. This allowed her to increase the intensity as she built back her strength. She says she would even sing along as the class danced. “Even with the classes being online, it was a great opportunity to get to know other people,” she says. “It really helped with the lack of social opportuH nities caused by the pandemic.” ■

Joanne Weeks taking part in the virtual GERAS DANCE class. The virtual GERAS DANCE class has elements that are both sitting and standing to accommodate various fitness levels of seniors.

This article was submitted by Hamilton Health Sciences Centre.

What is Home Care?

Home care is about trust. It is feeling comfortable with a provider ĐŽŵŝŶŐ ŝŶƚŽ ǇŽƵƌ ŚŽŵĞ ĂŶĚ͕ ƉŽƐƐŝďůǇ͕ ĂƐƐŝƐƟŶŐ ǇŽƵ ǁŝƚŚ ƚŚĞ ŵŽƐƚ ŝŶƟŵĂƚĞ ĐĂƌĞ͘ Bayshore’s home care services are extensive and varied, depending on your needs. They ƌĂŶŐĞ ĨƌŽŵ ŵĞĂů ƉƌĞƉĂƌĂƟŽŶ͕ ŵĞĚŝĐĂƟŽŶ ƌĞŵŝŶĚĞƌƐ͕ ĐŽŵƉĂŶŝŽŶƐŚŝƉ Žƌ ĂƐƐŝƐƟŶŐ ǁŝƚŚ errands to nursing, respite care, wound care, ƐĞƌŝŽƵƐ ŝŶũƵƌǇ ĐĂƌĞ͕ Žƌ ƉĂůůŝĂƟǀĞ ĐĂƌĞ͘

Caregivers wear PPE

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Home care is personalized for you, so you can experience the best in your day-to-day living – in your own home.

Support is just a phone call away.

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bayshore.ca www.hospitalnews.com

AUGUST 2021 HOSPITAL NEWS 27

SAFE MEDICATION

Serotonin syndrome made simple By Fabian Cretu, Christina Truong, and Certina Ho ver the past 12 hours, Sarah has experienced increased reflexes, sweating, nausea, tremors, agitation, and involuntary side-to-side eye movements. Her medical history includes depression and chronic pain, for which she takes fluoxetine daily and tramadol as needed, respectively. Her depression has been well-controlled on fluoxetine. While conducting a medication history, you find out that Sarah has recently started taking more of her tramadol and has been treating a cough with an over-the-counter (OTC) cough syrup containing dextromethorphan within the last day. You begin to suspect that Sarah is experiencing serotonin toxicity (aka serotonin syndrome).

RECOGNIZING AND DIAGNOSING SEROTONIN SYNDROME

Serotonin syndrome is a potentially life-threatening, drug-induced condition caused by increased serotonin (a neurotransmitter) in the synapses of the brain. Mild symptoms include dilated pupils, nervousness, nausea, diarrhea, and tremor. Moderate symptoms include sweating, agitation, hyperreflexia (increased reflexes), clonus (rhythmic muscle jerks) and ocular clonus (side-to-side eye movements). If left untreated, it may result in severe symptoms, such as a temperature of over 38.5°C, confusion, delirium, rhabdomyolysis (muscle breakdown), sustained clonus, or even death. Symptoms of serotonin toxicity may begin quickly, from within hours to one day of starting a new serotonergic medication (Table 1), or consuming high doses of serotonergic medications (e.g., overdoses). Patients should be informed and educated to recognize serotonin toxicity and to contact their primary care provider or pharmacist if they experience mild symptoms. If a patient is experiencing moderate symptoms, they should be referred to the emergency

room. If a patient is experiencing severe symptoms, they should be advised to call 911 immediately. Diagnosing serotonin toxicity is based on a thorough clinical (physical and neurologic) assessment and identification of the characteristic symptoms described above. A comprehensive medication history, including the use of OTC cough and cold products, illicit drugs, natural health products, and dietary supplements, is also important to the diagnosis.

Table 1: Medications Potentially Contributing to or Associated with Serotonin Syndrome (Note: This is not a comprehensive list of medications.)

SEROTONERGIC MEDICATIONS

Serotonin syndrome most often occurs when two or more serotonergic medications (Table 1) are used together. The three most common drug classes that are associated with serotonin syndrome are the monoamine oxidase inhibitors (MAOIs), selective serotonin reuptake inhibitors (SSRIs), and the serotonin-norepinephrine reuptake inhibitors (SNRIs) (Table 1). There are other medications that have been controversially implicated in serotonin syndrome, and some of these agents may be flagged by point-of-care clinical decision support system, such as, drug-drug interaction checking software, despite a lack of evidence. If patients have questions about the medications that they are taking, it is best to consult their primary care providers and/or pharmacists for further information. A 2018 article entitled “Demystifying serotonin syndrome” published in the Canadian Family Physician journal (available at https:// www.cfp.ca/content/64/10/720) included a handy infographic for healthcare providers.

PREVENTING AND MANAGING SEROTONIN SYNDROME

Serotonin syndrome may be prevented by avoiding serotonergic medications (Table 1). It is important to

Drug Classes

Medications (Example)

Common Use or Indications

MAOIs

Phenelzine

Depression

SSRIs

Fluoxetine

Depression

SNRIs

Venlafaxine

Depression

Tricyclic Antidepressants

Clomipramine

Depression

Analgesics

Tramadol

Pain

Natural Health Products

St. John’s wort

Depression

OTC Cough & Cold

Dextromethorphan

Cough

Illicit Drugs

MDMA (Ecstasy)

Recreational Use

consult your primary care provider or pharmacists before starting, stopping, or switching a medication. If there is a need to switch from one serotonergic agent to another, it is important to consider the original medication’s washout period to minimize the risk of serotonin syndrome while initiating the new medication. SwitchRx (https://www.switchrx.com/) is an online resource for healthcare professionals where suggestions for tapering and titration of medications can be found, particularly when there is a clinical need to adjust a patient’s medication therapy management. Execute caution when two or more serotonergic agents are used, with special attention when one is administered at a high dose. It is important to monitor patients who are taking serotonergic agents when adding another medication that may also increase serotonin – start low, increase the dose cautiously, and monitor patient signs and symptoms for 24 to 48 hours whenever a change in dose is made. When serotonin syndrome is recognized, prognosis is generally favourable. First line management involves discontinuing the serotonergic medications. Mild cases generally resolve within 24 to 72 hours upon removal of the causative agents; patients do not generally require hospital admission.

In moderate and severe cases, patients may require supportive care, for instance, administration of oxygen and IV fluids, continuous monitoring of cardiac and vital signs. Drug therapy may also be used to control agitation and tremors. In severely ill patients, managing hyperthermia (high body temperature) and increased muscle rigidity may include neuromuscular paralysis, sedation, and possible intubation. Once signs and symptoms of serotonin toxicity have resolved, initiate non-serotonergic therapeutic alternatives, or re-assess the need to resume the previously discontinued serotonergic medication(s), and if necessary, at low doses and increase the dose slowly. More information on serotonin syndrome can be found at the following resources: 1. Ables AZ, Nagubilli R. Prevention, recognition, and management of serotonin syndrome. Am Fam Physician 2010 May 1;81(9):1139-42. 2. Boyer EW. Serotonin syndrome (serotonin toxicity). UpToDate, Inc. Apr 05, 2021. 3. Foong AL, Grindrod KA, Patel T, Kellar J. Demystifying serotonin syndrome (or serotonin toxicity). Can Fam Physician. 2018 H Oct;64(10):720-727. ■

Fabian Cretu and Christina Truong are PharmD Students at the Leslie Dan Faculty of Pharmacy, University of Toronto; and Certina Ho is an Assistant Professor at the Department of Psychiatry and Leslie Dan Faculty of Pharmacy, University of Toronto. 28 HOSPITAL NEWS AUGUST 2021

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FROM THE CEO’S DESK

Peer support challenge during the pandemic By Janice M. Skot hat a year it’s been! In all my years in healthcare, both as a frontline nurse and then in leadership roles, I have never experienced a time like this. When the COVID-19 pandemic was declared in March 2020, we never imagined its severity, its length, or its impacts. And yet, as I reflect on this past year, I’m struck by the incredible courage, compassion and commitment of healthcare teams across Ontario. I’m personally impressed and humbled by what I’ve witnessed here at RVH and so proud of the cohesion and camaraderie shown by our healthcare professionals. Early on in the pandemic, we recognized our team needed extra support – in mind, body and spirit. We conducted a wellness survey to gauge the pulse of the organization and it showed that 80 per cent of respondents were worried about their own, or a family member’s, mental health. While our team cared for almost 600 very sick COVID-19 positive patients; faced constantly changing information about the virus; dealt with the increased use of PPE; they were also dealing with isolation, lack of social interaction with family and friends, online school and the long lines at the grocery store. Just like everyone else. I knew as the leader of this organization I needed to do more to support our entire workforce, we fondly call TEAM RVH. To do this I enlisted the help of other leaders in the organization, official and unofficial, from all levels, including physicians, housekeeping staff, social workers, security, Spiritual Care, Human Resources, Occupational Health and Wellness, Mental Health and Addictions, Corporate Communications and our own ONA President. Together we formed the Caring for YOU Committee and began to collectively meet the needs of TEAM RVH. From creating new website pages with pandemic-specific mental health resources, to sourcing rooms for safe,

Janice M. Skot

physically-distanced breaks, complete with very popular massage chairs; to delivering food to offices, the ideas flowing from this committee seemed endless. During one meeting we discussed the possibility of a peer-to-peer support program and that’s when we learned about the RISE (Resilience in Stressful Events) program. It was just what we were looking for and the perfect program to provide that extra support for TEAM RVH. While other hospitals have peer support programs, RVH is the first, and currently the only hospital in Canada, to fully and formally implement this program created by Johns Hopkins Medicine and supported by the Maryland Patient Safety Center. The program comes with the tools and templates required to become fully operational within 12-18 months. To meet our urgent need, we accelerated the implementation. We began recruiting for the program in March 2021 and by June we had 36 volunteer peer responders, trained by the Johns Hopkins RISE Team, ready to take a phone call from a colleague

in crisis. Our RISE Peer Responder team includes physicians, clinical and non-clinical staff, all who have been carefully selected and have joined RISE because they are all passionate about the wellbeing of their colleagues. They are not counsellors or therapists, but they are trained to listen and offer support when a peer is experiencing a stressful or difficult situation and, if required, refer the caller to more specific resources. Did I mention they are all volunteers? Each of them has committed to taking one, five-hour on-call shift every month. Dr. Ana Igric, a physician in our Intensive Care Unit, is one of our responders and here is what she had to say: “When I learned about the RISE program, I knew right away it was something I would want to be a part of. Who better to support a colleague through a difficult experience than someone who is a peer and may have had those same feelings or experienced something similar? I feel this program can complement an individual’s journey to wellness and resilience in the

face of stress at work. I love that the program is staffed by colleagues from many different disciplines and areas of the hospital, who have volunteered to support their colleagues.” RVH had many mental health and wellness resources already in place, but as Dr. Igric put it – it is the peerto-peer angle that makes this program unique. While the calls are anonymous, we have had callers reach out afterwards to let us know how well it went. Here’s what one of them had to say: “After a tough phone call with a patient expressing thoughts of selfharm, I was a little rattled and needed to talk about it. I was really nervous to call RISE, but talked myself into it and I am so glad I did. The person who answered didn’t ask me any personal questions, not even my name. She listened patiently, told me I had made a good decision to call her, expressed compassion and empathy for how I was feeling and made sure I had a strategy in place for some rest and decompression later that day. I had no idea what the call would be like, but it was truly the most supported I have ever felt after a tough moment at work. Thank you RISE Team!” That says it all! RISE is not just a pandemic support, it’s here to stay. Now that the program is fully established it resides with our Human Resources team under the leadership of Darrell Sewell, Vice President, Facilities and Chief Human Resources Officer. Healthcare is very rewarding, but it can also be very demanding and stressful. At RVH, we want to ensure our team is as healthy as they can be and ready to provide the high-quality, patient-centred care the people of this region have come to expect. I’m so proud of our new RISE program and our volunteer Peer Responders. Each time they take a RISE shift, they exemplify one of our core strategic directions - Value People and ensure we are living two of our core values Work Together and Respect All. With this new peer support program in place, we know that as we face the H future, we will go farther together. ■

Janice M. Skot, MHSc, CHE is President and CEO at Royal Victoria Regional Health Centre. www.hospitalnews.com

AUGUST 2021 HOSPITAL NEWS 29

EVIDENCE MATTERS

The latest evidence

on stem cell transplantation for multiple sclerosis

By Barbara Greenwood Dufour n Canada, an estimated 90,000 people, or about one in 400, live with multiple sclerosis (MS). It’s the most common neurological disorder affecting younger adults, with people typically experiencing their first symptoms in their early 30s. Autologous hematopoietic stem cell transplantation (AHSCT) is an emerging treatment that could be an option for people with relapsing-remitting MS, the most common type of MS. Relapsing-remitting MS is characterized by periods where symptoms get worse followed by periods of remission where some symptoms get better or remain the same. To treat relapsing-remitting MS, there are a number of disease-modifying therapies (DMTs) available. These therapies are used to reduce the frequency and intensity of relapses and delay the progression of disability. DMTs have been shown to be highly effective in the short term. But for most people, they cannot prevent the onset of progressive forms of MS, which have severe symptoms and limited treatment

30 HOSPITAL NEWS AUGUST 2021

options. In addition, DMTs are associated with adverse effects and may not work for some individuals. AHSCT could be an alternative to DMTs to treat aggressive or highly active relapsing-remitting MS when DMTs have had limited effect in controlling the disease. The AHSCT procedure aims to “reset” the immune system. It involves harvesting a person’s own stem cells, depleting their immune system using chemotherapy, then re-introducing the stem cells back into them. This reset can limit the progression of disability and reduce disease activity. Although AHSCT is an emerging health technology, the procedure has been performed for more than 25 years for MS, and it’s a well-established therapy for many blood cancers. In the last 10 years, researchers in Canada have become internationally recognized for playing a key role in developing and refining AHSCT. The procedure is offered in Alberta and Ontario as an experimental treatment and is in limited use outside of research settings.

CADTH conducted a horizon scan of various health information sources to give health care decision-makers in Canada an early overview of this technology and the emerging evidence. CADTH is an independent agency that finds, assesses, and summarizes the research on drugs, medical devices, tests, and procedures. The evidence on the clinical effectiveness of AHSCT suggests it might be an effective therapeutic option in people with relapsing-remitting MS who, despite being treated with DMTs, still show signs of high disease activity, such as frequent relapses and/ or the development of brain lesions. Compared with DMTs, AHSCT might extend the period of progression-free survival (the length of time after a person starts treatment that their disease doesn’t get worse) and be more effective at slowing or halting disease activity. For some people, it could improve disability and symptoms. And since AHSCT is a one-time procedure, it could lead to cost savings when compared with the recurring costs associ-

ated with DMTs. However, more research is needed to compare AHSCT with newer DMTs and to monitor longer-term outcomes. There’s some uncertainty about the safety of AHSCT. However, its safety profile has been improving over the last 25 years, as refinements to the treatment have reduced the risk of severe adverse events. Most safety concerns are largely similar to other stem cell transplant procedures. It’s not known how many people with MS in Canada might want AHSCT — for example, we don’t know how many people are unsatisfied with their current DMT regimen and would be interested in considering AHSCT as a potential alternative. However, there are reports of individuals from Canada seeking AHSCT abroad. If AHSCT were made broadly available in Canada, a limited number of people with MS would likely be eligible. Guidelines and recommendations generally suggest it can be offered to younger individuals with relapsing-remitting MS. For example, the Canawww.hospitalnews.com

EVIDENCE MATTERS dian MS working group on treatment optimization recommends that people between 18 and 31 years of age be considered for the procedure. This is because older people with MS typically have a higher level of disability and a higher risk of severe complications, which could reduce the likelihood of treatment success. Approximately 5,000 people living with MS in Canada are younger than 31 years of age. Although emerging evidence shows that AHSCT likely improves outcomes compared with DMTs, AHSCT isn’t intended to replace DMTs altogether. Instead, it could be a potential alternative for people who are still early in their disease progression but show a high level of disease activity despite receiving DMTs. For these people, AHSCT may offer a new option for improving their MS symptoms and quality of life.

Around the world, AHSCT has been used to treat more than 1,500 people with MS. At least three trials are currently in progress, and the results of these could provide a stronger evidence to inform decisions related to optimal AHSCT regimens and who should be eligible for the procedure. The full report on AHSCT for the treatment of MS is freely available on the CADTH website at cadth. ca. To learn more about our Horizon Scanning program, visit cadth.ca/ horizon-scanning, or to suggest a new or emerging health technology for CADTH to review, email us at HorizonScanning@cadth.ca. You can also follow us on Twitter @CADTH_ACMTS or speak to a Liaison Officer in your region: cadth.ca/contact-us/liaiH son-officers. ■

Barbara Greenwood Dufour is a knowledge mobilization officer at CADTH.

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