Tim Ramsay

Ottawa Hospital Research Institute, Ottawa, Ontario, Canada

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Publications (53)303.94 Total impact

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    ABSTRACT: BK virus infection is a significant complication of modern immunosuppression used in kidney transplantation. Viral reactivation occurs first in the urine (BK viruria) and is associated with a high risk of transplant failure. There are currently no therapies to prevent or treat BK virus infection. Quinolone antibiotics have antiviral properties against BK virus but efficacy at preventing this infection has not been shown in prospective controlled studies.
    JAMA The Journal of the American Medical Association 11/2014; · 29.98 Impact Factor
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    ABSTRACT: Background Proteinuria has been associated with transplant loss and mortality in kidney transplant recipients. Both spot samples (albumin-creatinine ratio [ACR] and protein-creatinine ratio [PCR]) and 24-hour collections (albumin excretion rate [AER] and protein excretion rate [PER]) have been used to quantify protein excretion, but which measurement is a better predictor of outcomes in kidney transplantation remains uncertain. Study Design Observational cohort study. Setting & Participants Tertiary care center, 207 kidney transplant recipients who were enrolled in a prospective study to measure glomerular filtration rate. Consecutive patients who met inclusion criteria were approached. Predictors ACR and PCR in spot urine samples, AER and PER in 24-hour urine collections. Outcomes Primary outcome included transplant loss, doubling of serum creatinine level, or death. Measurements Urine and serum creatinine were measured using a modified Jaffé reaction that had not been standardized by isotope-dilution mass spectrometry. Urine albumin was measured by immunoturbidimetry. Urine protein was measured by pyrogallol red molybdate complex formation using a timed end point method. Results Mean follow-up was 6.4 years and 22% developed the primary end point. Multivariable-adjusted areas under the receiver operating characteristic curves were similar for the different protein measurements: ACR (0.85; 95% CI, 0.79-0.89), PCR (0.84; 95% CI, 0.79-0.89), PER (0.86; 95% CI, 0.80-0.90), and AER (0.83; 95% CI, 0.78-0.88). C Index values also were similar for the different proteinuria measurements: 0.87 (95% CI, 0.79-0.95), 0.86 (95% CI, 0.79-0.94), 0.88 (95% CI, 0.82-0.94), and 0.86 (95% CI, 0.77-0.95) for log(ACR), log(PCR), log(PER), and log(AER), respectively. Limitations Single-center study. Measurement of proteinuria was at variable times posttransplantation. Conclusions Spot and 24-hour measurements of albumin and protein excretion are similar predictors of doubling of serum creatinine level, transplant loss, and death. Thus, spot urine samples are a suitable alternative to 24-hour urine collection for measuring protein excretion in this population.
    American Journal of Kidney Diseases 10/2014; · 5.29 Impact Factor
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    ABSTRACT: O objetivo deste estudo foi avaliar e comparar as competências em saúde global em estudantes de reabilitação. Trata-se de um estudo transversal com um survey on-line para os estudantes de fisioterapia e terapia ocupacional de cinco universidades em Ontário – Canadá. Foi utilizada a estatística descritiva para analisar o conhecimento percebido dos alunos, habilidades e necessidades de aprendizagem na área da saúde global. Utilizou-se o teste de qui-quadrado, com um conjunto de significância de p<0,05 para comparação de resultados entre as profissões. 166 alunos responderam à pesquisa. Em geral, tanto os estudantes de fisioterapia e terapia ocupacional tiveram escores mais elevados nos itens referentes à “relação entre trabalho e saúde”, “relação entre renda e saúde” e “posição socioeconômica (PSE) e impacto na saúde” como obtiveram escores menores nos itens sobre “acesso aos cuidados de saúde em países de baixa renda”, “mecanismos pelos quais as disparidades raciais e étnicas existentes” e 1“estereótipos raciais e decisão clínica”. Estudantes de terapia ocupacional consideraram como importantes a aprendizagem sobre determinantes sociais da saúde (p=0,03). Este artigo destaca várias oportunidades de melhoria na educação em saúde global para estudantes de fisioterapia e terapia ocupacional. Os educadores e os profissionais devem considerar o desenvolvimento de estratégias para lidar com essas necessidades e proporcionar mais oportunidades em saúde global nos programas de graduação em fisioterapia e terapia ocupacional.
    Sanare Revista Sobralense de Politicas Publicas. 06/2014; 13(1):7-17.
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    ABSTRACT: Controversies regarding the process and timing of the determination of death for controlled organ donation after circulatory death persist. This study assessed the feasibility of conducting a prospective, observational study of continuous monitoring of vital signs for 30 minutes after the clinical determination of death in five Canadian ICUs. Waveform data were analyzed. Prospective observational cohort study. One pediatric and four adult Canadian ICUs. One month of age or older, admitted to the ICU, and for whom a consensual decision to withdraw life-sustaining therapies had been made, with an anticipation of imminent death. None. Invasive arterial blood pressure, electrocardiogram, and oxygen saturation plethysmography activity were recorded and reviewed for 30 minutes after declaration of death. Feasibility was assessed (recruitment, consent rate, protocol compliance, and staff satisfaction). Of 188 subjects screened over 16 months, 41 subjects were enrolled (87% consent rate). Data collection was complete for 30 subjects (73% protocol compliance). In four subjects, arterial blood pressure resumed following cessation of activity. The longest period of cessation of arterial blood pressure before resumption was 89 seconds. The duration of resumed activity ranged from 1 to 172 seconds. No cases of sustained resumption of arterial blood pressure activity were recorded, and no instances of clinical autoresuscitation were reported. In nearly all patients (27 of 30), electrocardiogram activity continued after the disappearance of arterial blood pressure. This is the first observational study to prospectively collect waveform data for 30 minutes after the declaration of death. A future larger study may support initial data suggesting that circulatory function does not resume after more than 89 seconds of absence. Furthermore, persistence of cardiac electrical activity with the documented absence of circulation may not be relevant to declaration of death.
    Critical care medicine 05/2014; · 6.37 Impact Factor
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    ABSTRACT: Prolonged ventilation and failed extubation are associated with increased harm and cost. The added value of heart and respiratory rate variability (HRV and RRV) during spontaneous breathing trials (SBTs) to predict extubation failure remains unknown. We enrolled 721 patients in a multicenter (12 sites), prospective, observational study, evaluating clinical estimates of risk of extubation failure, physiologic measures recorded during SBTs, HRV and RRV recorded before and during the last SBT prior to extubation, and extubation outcomes. We excluded 287 patients because of protocol or technical violations, or poor data quality. Measures of variability (97 HRV, 82 RRV) were calculated from electrocardiogram and capnography waveforms followed by automated cleaning and variability analysis using Continuous Individualized Multiorgan Variability Analysis (CIMVATM) software. Repeated randomized sub-sampling with training, validation, and testing were used to derive and compare predictive models. Of 434 patients with high quality data, 51 (12%) failed extubation. Two HRV and eight RRV measures showed statistically significant association with extubation failure (P <0.0041, 5% false discovery rate). An ensemble average of five univariate logistic regression models using RRV during SBT, yielding a probability of extubation failure (called WAVE score), demonstrated optimal predictive capacity. With repeated random sub-sampling and testing, the model showed mean receiver operating characteristic area under the curve (ROC AUC) of 0.69, higher than heart rate (0.51), rapid shallow breathing index (RBSI; 0.61) and respiratory rate (0.63). After deriving a WAVE model based on all data, training-set performance demonstrated that the model increased its predictive power when applied to patients conventionally considered high risk: a WAVE Score >0.5 in patients with RSBI >105 and perceived high-risk of failure yielded a fold increase in risk of extubation failure of 3.0 (95% confidence interval (CI) 1.2 to 5.2) and 3.5 (95% CI 1.9 to 5.4), respectively. Altered HRV and RRV (during the SBT prior to extubation) are significantly associated with extubation failure. A predictive model using RRV during the last SBT provided optimal accuracy of prediction in all patients, with improved accuracy when combined with clinical impression or RSBI. This model requires a validation cohort to evaluate accuracy and generalizability.Trial registration: ClinicalTrials.gov NCT01237886.
    Critical care (London, England) 04/2014; 18(2):R65. · 4.72 Impact Factor
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    ABSTRACT: A growing number of healthcare policy initiatives around the world have focused on the continuum of care amongst the elderly, calling for renewed investments in integrated care to promote healthy aging and to reduce health system costs. The study objective was to examine healthcare costs and cost drivers for myocardial infarction (AMI) among Canadian Seniors across the care continuum from 2004 to 2012 in Ontario, Canada. Cost estimates represented direct community and hospital-based costs including physician services, diagnostic-testing, pharmaceuticals and hospitalizations obtained from Canadian healthcare data sources. Separate costs were calculated for pre-state care, the hospital event, and post-state care over a 6 year care continuum. Socio-demographic and co-morbid cost drivers were studied using negative binomial regression in a cohort of 16,450 first-time AMI seniors. The average cost per patient across a six-year care continuum was $28,169 in 2008 constant Canadian dollars. Almost three-quarters of these costs were derived from the event phase ($20,794), while pre-state and post-state costs made up 12% and 14%, respectively ($3400 and $3974). Pre-state costs per patient day were half of post-state costs ($3.11 versus $6.32 per day) when adjusted for survival. Socio-demographic characteristics including age, gender and patient’s urban/rural residence, and co-morbid illnesses were key cost drivers across the phases of care. This study provides a person-centered health system perspective in the economic burden of AMI in Canada’s elderly and will inform health policy related to integrated care strategies for heart disease in seniors.
    The Journal of the Economics of Ageing. 04/2014; 3:44–49.
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    ABSTRACT: This study focused on health care staff (HCS) responsible for activating the medical emergency team (MET) at a pediatric tertiary hospital using a well-established rapid response system. Our goals were to report the patient characteristics, MET interventions, and disposition by activating HCS. This is a retrospective cohort study of pediatric patients who received MET activation at the Children's Hospital of Eastern Ontario in Ottawa, Canada. Data were obtained from a prospectively maintained rapid response system database. The primary outcome was PICU admission, with the number and type of interventions performed as secondary outcomes. The most common MET activators were physicians (410, 53.3%) with nurses generating a comparable number (367, 47.7%). Significant differences in PICU admission rates were observed between activator groups, with physicians having statistically higher PICU admission rates when compared with nurses (25.2% vs 15.0%, P = .001). Compared with physicians, nursing-led activations on surgical patients had significantly lower odds of PICU admission relative to medical patients (odds ratio 0.19 vs 0.67; P = .03). No significant difference was observed in the type or number of interventions between any subgroup based on patient (surgery vs medical) or activator type. This study suggests that when nurses activate MET, patients are less likely to be transferred to the PICU despite receiving similar type and number of interventions. Our study results may help direct education initiatives aimed at enhancing the effectiveness of the afferent limb through informing specific HCS as to the importance of their role in using the MET.
    Hospital pediatrics. 03/2014; 4(2):99-105.
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    ABSTRACT: Quantification of proteinuria (albuminuria) in renal transplant recipients is important for diagnostic and prognostic purposes. Recent guidelines have recommended quantification of proteinuria by spot protein-to-creatinine ratio (PCR) or spot albumin-to-creatinine ratio (ACR). Validity of spot measurements remains unclear in renal transplant recipients. Systematic review of adult kidney transplant recipients. Studies that reported the diagnostic accuracy of PCR or ACR as compared with 24-h urine protein or albumin excretion in renal transplant recipients were included. The search identified 8 studies involving 1871 renal transplant recipients. The correlation of the PCR to 24-h protein ranged from 0.772 to 0.998 with a median value of 0.92. PCR sensitivity ranged from 63 to 99 (50% of sensitivities were >90%); PCR specificity varied from 73 to 99 (50% of specificities were >90%). Only one study reported the bias; percent bias ranged from 12 to 21% and accuracy (within 30% of 24 h urine protein) ranged from 47 to 56% depending on the degree of proteinuria. For the ACR, percent bias ranged from 9 to 21%, and the accuracy (within 30%) ranged from 38 to 80%. The data regarding diagnostic accuracy of PCR and ACR is limited. Only one report studied the absolute measures of agreement (bias and accuracy). We recommend verifying PCR and ACR measurements with a 24-h protein before making any major diagnostic (e.g. biopsy) or therapeutic (e.g. change in immunosuppressive agents) decisions in this population.
    Nephrology Dialysis Transplantation 01/2014; · 3.37 Impact Factor
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    British Journal of Medicine & Medical Research. 01/2014; 4(10):2002-2013.
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    ABSTRACT: Cardiac and Thoracic Surgery PostersSESSION TYPE: Original Investigation PosterPRESENTED ON: Wednesday, October 30, 2013 at 01:30 PM - 02:30 PMPURPOSE: The ability to accurately characterize a pulmonary air leak (PAL) is an essential skill for those caring for thoracic surgery patients. The objective was to evaluate inter-observer reliability in PAL assessments using analog (Pleurevac®, Teleflex) and digital (Thopaz®, Medela) pleural drainage systems.METHODS: Lung resection patients with a PAL were prospectively evaluated by at least 1 thoracic surgeon, 1 surgical resident, and 1-2 nurses using a standardized questionnaire. Each patient was assessed at the bedside first with the analog system and then the digital system. The thoracic surgeon evaluation was considered the reference standard for comparison. Analog Air leak severity was classified using the Robert David Cerfolio (RDC) system. Kappa (k) statistics were used to quantify agreement between observers.RESULTS: A total of 128 PAL evaluations were completed in 30 patients (thoracic surgeon=30; nurse=56; resident=30; physiotherapists=12). Mean (SD) time between analog and digital assessment was 2.16 (1.66) hours. For PAL severity, the overall level of observer agreement using the analog system was slight k=0.03 (CI: -0.04, 0.11); p=0.40. Agreement overall using the digital system was substantial k=0.61 (CI: 0.49, 0.73); p < 0.01. Across all subcategories of allied health professionals, a consistent increased level of agreement in air leak severity assessment using the digital chest drainage was observed.CONCLUSIONS: With the analog drainage systems, there was poor inter-observer reliability in quantifying PAL severity. Digital pleural drainage technology improves consistency between thoracic surgeons and other members of the allied health care team in bedside evaluation of PAL.CLINICAL IMPLICATIONS: Digital pleural drainage technology improves consistency between thoracic surgeons and other members of the allied health care team in bedside evaluation of PAL.DISCLOSURE: The following authors have nothing to disclose: Anna McGuire, Sebastien Gilbert, William Petrcich, Tim Ramsay, Andrew Seely, Donna Maziak, Sudhir Sundaresan, Farid ShamjiNo Product/Research Disclosure Information.
    Chest 10/2013; 144(4_MeetingAbstracts):109A. · 7.13 Impact Factor
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    ABSTRACT: Background: There is an increased interest in global health among medical students, family medicine residents, and medical educators. This paper is based on research to assess confidence in knowledge and skills in global health in family medicine residents in five universities across Ontario. Methods: A web-based survey was sent to 166 first-year family medicine residents from five universities within Ontario. Descriptive statistics were used to analyze residents’ confidence in their knowledge and skills in global health. The strength of association between each of the self-perceived knowledge and skills variables was assessed by the Spearman correlation coefficient Results: The response rate ranged from 29% to 66% across the five universities. Self-perceived knowledge scores revealed that 34.3% of the respondents were very confident, 51.9% were somewhat confident, and 13.8% were not at all confident about their global health knowledge. Participants' confidence scores were lower in relation to knowledge of access to health care for low income nations (44.3%), and were better on their global health skills related to working in a team (70.9%) and listening actively to patients' concerns (64.6%). Conclusions: The global health competency scale has identified key areas of strengths and weaknesses of family medicine programs in global health education. This can be used to evaluate and analyze progress over time.
    Canadian Medical Education Journal. 09/2013; 4(2):e10-e17.
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    ABSTRACT: There has been limited research exploring socioeconomic inequity in targeted preventive care for acute myocardial infarction (AMI). The objective of this study was to examine socioeconomic disparities in the use of primary and secondary preventive services relevant to the identification and management of heart disease in a cohort of patients with AMI. Preventive services used before the AMI event were examined in a cohort of 30,491 patients with first-time AMI in Ontario, Canada from 2010 to 2012. Using logistic regression, socioeconomic differences in lipid testing, glucose testing, stress testing, electrocardiography (ECG), and echocardiography in middle-aged and older patients were examined. For many of the services, there were no differences in the use of primary and secondary preventive services between patients according to socioeconomic status; however, a number of exceptions were found. Controlling for other factors, we found that for primary preventive services, low-income middle-aged patients had 13% (95% confidence interval [CI], 0.790-0.967) and 10% (95% CI, 0.812-0.997) lower odds of receiving lipid and glucose testing, respectively, when compared with high-income middle-aged patients. Controlling for other factors, we found that for secondary preventive services, low-income middle-aged and older patients had 24% (95% CI, 1.087-1.415) and 10% (95% CI, 1.012-1.202) higher odds of receiving echocardiography when compared with their high-income counterparts. Socioeconomic disparities in primary and secondary preventive services for patients with AMI could not be demonstrated in many instances. However, inequities in primary preventive care were found in middle-aged patients receiving lipid and glucose testing, which may have implications for Canadian health policy to ensure healthy aging across the age spectrum.
    The Canadian journal of cardiology 08/2013; · 3.12 Impact Factor
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    ABSTRACT: Chinese translation The role of aspirin in thromboprophylaxis after total hip arthroplasty (THA) is controversial. To compare extended prophylaxis with aspirin and dalteparin for prevention of symptomatic venous thromboembolism (VTE) after THA. Multicenter randomized, controlled trial with a noninferiority design based on a minimal clinically important difference of 2.0%. Randomization was electronically generated; patients were assigned to a treatment group through a Web-based program. Patients, physicians, study coordinators, health care team members, outcome adjudicators, and data analysts were blinded to interventions. (Current Controlled Trials: ISRCTN11902170) 12 tertiary care orthopedic referral centers in Canada. 778 patients who had elective unilateral THA between 2007 and 2010. After an initial 10 days of dalteparin prophylaxis after elective THA, patients were randomly assigned to 28 days of dalteparin (n = 400) or aspirin (n = 386). Symptomatic VTE confirmed by objective testing (primary efficacy outcome) and bleeding. Five of 398 patients (1.3%) randomly assigned to dalteparin and 1 of 380 (0.3%) randomly assigned to aspirin had VTE (absolute difference, 1.0 percentage point [95% CI, -0.5 to 2.5 percentage points]). Aspirin was noninferior (P < 0.001) but not superior (P = 0.22) to dalteparin. Clinically significant bleeding occurred in 5 patients (1.3%) receiving dalteparin and 2 (0.5%) receiving aspirin. The absolute between-group difference in a composite of all VTE and clinically significant bleeding events was 1.7 percentage points (CI, -0.3 to 3.8 percentage points; P = 0.091) in favor of aspirin. The study was halted prematurely because of difficulty with patient recruitment. Extended prophylaxis for 28 days with aspirin was noninferior to and as safe as dalteparin for the prevention of VTE after THA in patients who initially received dalteparin for 10 days. Given its low cost and greater convenience, aspirin may be considered a reasonable alternative for extended thromboprophylaxis after THA. Canadian Institutes of Health Research.
    Annals of internal medicine 06/2013; 158(11):800-6. · 13.98 Impact Factor
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    ABSTRACT: OBJECTIVE: To investigate the association between helmet legislation and admissions to hospital for cycling related head injuries among young people and adults in Canada. DESIGN: Interrupted time series analysis using data from the National Trauma Registry Minimum Data Set. SETTING: Canadian provinces and territories; between 1994 and 2003, six of 10 provinces implemented helmet legislation. PARTICIPANTS: All admissions (n=66 716) to acute care hospitals in Canada owing to cycling related injury between 1994 and 2008. MAIN OUTCOME MEASURE: Rate of admissions to hospital for cycling related head injuries before and after the implementation of provincial helmet legislation. RESULTS: Between 1994 and 2008, 66 716 hospital admissions were for cycling related injuries in Canada. Between 1994 and 2003, the rate of head injuries among young people decreased by 54.0% (95% confidence interval 48.2% to 59.8%) in provinces with helmet legislation compared with 33.1% (23.3% to 42.9%) in provinces and territories without legislation. Among adults, the rate of head injuries decreased by 26.0% (16.0% to 36.3%) in provinces with legislation but remained constant in provinces and territories without legislation. After taking baseline trends into consideration, however, we were unable to detect an independent effect of legislation on the rate of hospital admissions for cycling related head injuries. CONCLUSIONS: Reductions in the rates of admissions to hospital for cycling related head injuries were greater in provinces with helmet legislation, but injury rates were already decreasing before the implementation of legislation and the rate of decline was not appreciably altered on introduction of legislation. While helmets reduce the risk of head injuries and we encourage their use, in the Canadian context of existing safety campaigns, improvements to the cycling infrastructure, and the passive uptake of helmets, the incremental contribution of provincial helmet legislation to reduce hospital admissions for head injuries seems to have been minimal.
    BMJ (online) 05/2013; 346:f2674. · 17.22 Impact Factor
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    ABSTRACT: OBJECTIVE:: Limited evidence exists on the use of corticosteroids in pediatric shock. We sought to determine physicians' practices and beliefs with regard to the management of pediatric shock. DESIGN:: Cross-sectional, Internet-based survey. SETTING:: Canada. SUBJECTS:: Physicians identified as practicing pediatric intensive care in any of 15 academic centers. MEASUREMENTS AND MAIN RESULTS:: Seventy of 97 physicians (72.2%) responded. Physicians stated that they were more likely to prescribe steroids for septic shock than for shock following cardiac surgery (odds ratio, 1.9 [95% CI, 0.9-4.3]) or trauma (odds ratio, 11.46 [95% CI, 2.5-51.2]), and 91.4% (64/70) would administer steroids to patients who had received 60 cc/kg of fluid and two or more vasoactive medications. Thirty-five percent of respondents (25/70) reported that they rarely or never conducted adrenal axis testing before giving steroids to patients in shock. Eighty-seven percent of respondents (61/70) stated that the role of steroids in the treatment of fluid and/or vasoactive drug-dependent shock needed to be clarified and that 84.3% would be willing to randomize patients into a trial of steroid efficacy who were fluid resuscitated and on one high-dose vasoactive medication. However, 74.3% stated that they would start open-label steroids in patients who required two high-dose vasoactive medications. CONCLUSIONS:: This survey provides information on the stated beliefs and practices of pediatric critical care physicians with regard to the use of steroids in fluid and/or vasoactive drug-dependent shock. Clinicians feel that the role of steroids in shock still requires clarification and that they would be willing to randomize patients into a trial. This survey may be useful as an initial framework for the development of a future trial on the use of steroids in pediatric shock.
    Pediatric Critical Care Medicine 04/2013; · 2.35 Impact Factor
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    ABSTRACT: Context:Recent studies in critically ill populations have suggested both adrenal insufficiency (AI) and vitamin D deficiency to be associated with worse clinical outcome. There are multiple mechanisms through which these pleiotropic hormones might synergistically influence critical illness.Objective:The aim of the study was to investigate potential relationships between vitamin D status, adrenal status, and cardiovascular dysfunction in critically ill children.Design:We conducted a secondary analysis of data from a prospective cohort study.Setting and Patients:The study was conducted on 319 children admitted to 6 Canadian tertiary-care pediatric intensive care units.Main Outcome Measures:Vitamin D status was determined through total 25-hydroxyvitamin D (25OHD) levels. AI was defined as a cortisol increment under 9 μg/dL after low-dose cosyntropin. Clinically significant cardiovascular dysfunction was defined as catecholamine requirement during pediatric intensive care unit admission.Results:Using 3 different thresholds to define vitamin D deficiency, no association was found between vitamin D status and AI. Furthermore, linear regression failed to identify a relationship between 25OHD and baseline or post-cosyntropin cortisol. However, the association between AI and cardiovascular dysfunction was influenced by vitamin D status; compared to children with 25OHD above 30 nmol/L, AI in the vitamin D-deficient group was associated with significantly higher odds of catecholamine use (odds ratio, 5.29 vs 1.63; P = .046).Conclusions:We did not find evidence of a direct association between vitamin D status and critical illness-related AI. However, our results do suggest that vitamin D deficiency exacerbates the effect of AI on cardiovascular stability in critically ill children.
    The Journal of Clinical Endocrinology and Metabolism 04/2013; · 6.31 Impact Factor
  • Journal of Critical Care 02/2013; 28(1):e16-e16. · 2.50 Impact Factor
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    Dataset: 403423
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    Dataset: 2012.jama
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    Dataset: 2012.jama

Publication Stats

656 Citations
303.94 Total Impact Points

Institutions

  • 2009–2014
    • Ottawa Hospital Research Institute
      • Clinical Epidemiology Program
      Ottawa, Ontario, Canada
    • Queen's University
      • Department of Medicine
      Kingston, Ontario, Canada
  • 2007–2014
    • University of Ottawa
      • • Department of Epidemiology and Community Medicine
      • • Department of Surgery
      Ottawa, Ontario, Canada
  • 2013
    • University of Manitoba
      Winnipeg, Manitoba, Canada
  • 2009–2011
    • The Ottawa Hospital
      Ottawa, Ontario, Canada