ABSTRACT
Objectives and Study/Background: The novel coronavirus (SARS-CoV-2) or COVID-19 pandemic has significantly impacted traditional medical education strategies, serving as a catalyst for innovative transformation of educational curriculum. The medical learning environment required a swift transition from exclusively in-person training experiences to virtual and online learning formats. Graduate medical education has also been significantly affected, with some trainees redeployed from their chosen specialties to the front lines of COVID-19 units. For other graduate trainees in less heavily strained locations, direct patient contact, including procedural training, has been limited in order to reduce risk of exposure. Clinical and basic science research for pediatric gastroenterology (GI) fellows have also been restricted. Medical trainees have come to depend on technological adaptation in order to continue their education for their future medical practice. These online opportunities include virtual lectures, case reviews, journal clubs, radiology and pathology reviews, telehealth patient encounters, clinical practice questions, research or multidisciplinary discussions, and article reviews. While these tools have been vital to the continuation of medical education, they are not ideal for learning the “art of medicine”. Pandemic restrictions provide a challenge to the next generation of physicians, not only in their ability to critically evaluate each patient as an individual, but also in their capacity to observe and discuss physician-educator medical decision making and patient-provider communication. Methods: A virtual discussion-based curriculum was developed at Stanford University in July 2020. Using video conferencing technology, the pediatric GI fellows were invited to participate in optional sessions with an individual medical educator (referred to as a “Guru”) within the division. Each session was dedicated to a designated topic that was within the Guru's expertise. The educators were asked to provide 1-2 useful and up to date journal articles that would enhance the trainee's medical practice. Sessions included a brief topic introduction lecture, given by one of the second year fellows. The rest of the session was then designed as an open forum for discussion. Conversation included lively analysis of clinical guidelines, real life inpatient or outpatient clinical case reviews, and advice about communication or medical decision-making strategies. Results: Gabbing with the Guru sessions were held weekly, starting in July 2020. Sessions ranged from 45 minutes to 1 hour in length (Figure 1). There were 28 sessions, which included topics related to outpatient, inpatient, procedural, and career development learning. The mean fellow participation for all sessions was 66.1%. An optional feedback survey found that 100% of responders (n= 5) believed that the sessions and selected journal articles were helpful for their learning and clinical practice. All responders also indicated a strong preference to continue the curriculum as weekly, 1-hour long sessions. Conclusion: There are many challenges to obtaining comprehensive medical education training during the COVID-19 pandemic. While transition of curriculum to virtual format has allowed for trainees to continue necessary learning, most of these teaching modalities do not promote a physician's ability to acquire skills that allow them to practice the “art of medicine”. The innovative Gabbing with the Guru curriculum enables pediatric GI fellows to participate in small-group active learning sessions with experts in the field, during a time when in-person training is restricted. Consistent optional participation from fellows (Figure 2) provides evidence that trainees find the sessions valuable to their learning. The format could prove effective for all graduate medical education trainees and across training programs or institutions.
ABSTRACT
Background: The impact of severe acute respiratory syndrome coronavirus 2 (SARS-CoV2) on children with underlying liver disease (LD) is unknown. We aim to report outcomes for pediatric patients with LD from the joint North American Society for Pediatric Gastroenterology, Hepatology and Nutrition (NASPGHAN) and the Society of Pediatric Liver Transplantation (SPLIT) SARS-CoV2 registry Methods: We collected data from patients younger than 21 years with LD from 6 countries and laboratory-confirmed SARS-CoV2 infection reported to a multicenter observational cohort study between April 2020 and May 2021. Results: Seventy-three (59% male,55% white, 23% Hispanic) children with a median age of 9 years were reported in the registry. The most common causes of LD were biliary atresia (22%) followed by autoimmune hepatitis (16%) and non-alcoholic fatty liver disease (16%). Five patients (7%) presented in acute liver failure (ALF);all recovered without the need for a liver transplant. Four patients presented with multisystem inflammatory syndrome in children (2 with ALF, 2 without ALF) with one death reported. The most common presenting symptoms were constitutional (49%) including fever and fatigue followed by respiratory symptoms (47%). Twenty two percent (n=16) of patients were asymptomatic at the time of diagnosis. Twentythree percent had radiologic evidence of pneumonia and 14% reported co-infections. Median peak INR was 1.4, peak total bilirubin 2.9 (mg/dl), peak ALT 129 (IU/l) and nadir albumin 3.1 (g/dl). Sixty-four percent of patients required hospitalization;40% (n=19) in the ICU and 60% (n=28) non-ICU for a median of 6 and 7 days, respectively. Twenty-two percent of patients required respiratory support including mechanical ventilation (n=6), high-frequency oscillatory ventilation (n=3), highflow nasal cannula (n=5) and regular nasal cannula (n=2) for a median of 6 days. Nine patients required vasoactive agents, 3 required renal replacement therapy and 2 patients required ECMO. Sixty-six percent did not receive any SARSCoV2 directed treatment. Twelve (16%) patients developed new liver-related complications including ascites (n=9), GI bleeding (n=2), encephalopathy (n=3), progression of endstage liver disease (n=2) and infection (n=1). There were a total of 3 (4.1%) deaths (20yr, 17yr and 6month of age at time of death) reported secondary to acute on chronic liver failure with respiratory failure and multiorgan failure Conclusion: Contrary to healthy children, almost 2/3rd pediatric patients with LD testing positive for SARS-CoV2 required hospitalization with death reported in 4% of cases. Acute liver failure is rare with SARS-CoV2 infection with recovery reported without the need for liver transplantation. Close monitoring is needed due to an increased risk of underlying liver disease complications and death, particularly in children with end-stage liver disease awaiting transplantation.