Canadian infants presenting with Brief Resolved Unexplained Events (BRUEs) and validation of clinical prediction rules for risk stratification: a protocol for a multicentre, retrospective cohort study.

INTRODUCTION: Brief Resolved Unexplained Events (BRUEs) are a common presentation among infants. While most of these events are benign and self-limited, guidelines published by the American Academy of Pediatrics inaccurately identify many patients as higher-risk of a serious underlying aetiology (positive predictive value 5%). Recently, new clinical prediction rules have been derived to more accurately stratify patients. This data were however geographically limited to the USA, with no large studies to date assessing the BRUE population in a different healthcare setting. The study's aim is to describe the clinical management and outcomes of infants presenting to Canadian hospitals with BRUEs and to externally validate the BRUE clinical prediction rules in identified cases. METHODS AND ANALYSIS: This is a multicentre retrospective study, conducted within the Canadian Paediatric Inpatient Research Network (PIRN). Infants (<1 year) presenting with a BRUE at one of 11 Canadian paediatric centres between 1 January 2017 and 31 December 2021 will be included. Eligible patients will be identified using diagnostic codes.The primary outcome will be the presence of a serious underlying illness. Secondary outcomes will include BRUE recurrence and length of hospital stay. We will describe the rates of hospital admissions and whether hospitalisation was associated with an earlier diagnosis or treatment. Variation across Canadian hospitals will be assessed using intraclass correlation coefficient. To validate the newly developed clinical prediction rule, measures of goodness of fit will be evaluated. For this validation, a sample size of 1182 is required to provide a power of 80% to detect patients with a serious underlying illness with a significance level of 5%. ETHICS AND DISSEMINATION: Ethics approval has been granted by the UBC Children's and Women's Research Board (H21-02357). The results of this study will be disseminated as peer-reviewed manuscripts and presentations at national and international conferences.

Completeness of Medication Reconciliation Performed by Pediatric Resident Physicians at Hospital Admission for Asthma.

BACKGROUND: Medication errors at hospital admission, though preventable, continue to be common. The process of medication reconciliation has been identified as an important tool in reducing medication errors. The first step in medication reconciliation involves documenting a patient's best possible medication history (BPMH); at the authors' tertiary pediatric hospital, this step is completed at time of admission by resident physicians. OBJECTIVES: To describe and quantify the completeness of admission BPMH by resident physicians for pediatric inpatients with asthma. METHODS: This single-centre, retrospective chart review evaluated documentation of admission medication reconciliation for pediatric inpatients with asthma who were admitted between January 2016 and December 2017. Medication reconciliation forms were deemed incomplete if records for asthma medications were missing drug name, inhaler strength or oral drug dose, directions for use, or evidence of reconciliation. RESULTS: A total of 241 charts were evaluated, of which 97 (40%) had incomplete documentation for at least 1 medication; in particular, 48 (37%) of the 130 inhaled corticosteroid orders were missing inhaler strength. For most of the charts with incomplete medication history (68% [66/97]), no reason was documented; however, review of the medication reconciliation forms and physician notes revealed that families might have been unsure of a patient's home medications or physicians might have left it to the pharmacy to clarify medication doses. CONCLUSIONS: Documentation of inhaler medications on admission medication reconciliation forms completed by resident physicians for pediatric patients with asthma was often incomplete. Future quality improvement interventions, including resident and patient education, are required at the study institution. Collaboration with pharmacy services is also likely to improve completeness of the medication reconciliation process.

CONTEXTE: Bien qu'elles soient évitables, les erreurs de médication au moment de l'admission à l'hôpital sont encore répandues. Le processus du bilan comparatif des médicaments a été reconnu comme étant un outil important pour réduire ces erreurs. La première étape du bilan comparatif des médicaments vise à décrire le meilleur schéma thérapeutique possible (MSTP) du patient; dans l'hôpital pédiatrique tertiaire des auteurs, les médecins résidents se chargent de cette étape au moment de l'admission. OBJECTIFS: Décrire et quantifier le degré d'exhaustivité du MSTP réalisé par les médecins résidents pour les patients en pédiatrie souffrant d'asthme. MÉTHODES: Cet examen rétrospectif unicentrique des dossiers a permis d'évaluer l'élaboration du bilan comparatif des médicaments à l'admission en pédiatrie des patients souffrant d'asthme entre janvier 2016 et décembre 2017. Les formulaires de bilan comparatif des médicaments étaient jugés incomplets si les dossiers relatifs aux médicaments contre l'asthme n'indiquaient pas le nom du médicament, la force de l'inhalateur ou la dose orale du médicament, le mode d'emploi ou les preuves de conciliation médicamenteuse. RÉSULTATS: L'évaluation portait sur 241 tableaux; au moins 1 médicament manquait dans la description de 97 d'entre eux (40 %); en particulier la force de l'inhalateur ne figurait pas dans 48 (37 %) des 130 ordonnances relatives aux corticostéroïdes administrés par inhalation. La plupart des tableaux dont l'histoire pharmacothérapeutique était incomplète (68 % [66/97]) n'en indiquaient pas la raison; cependant, l'examen des formulaires du bilan comparatif des médicaments et les notes des médecins ont révélé que les familles n'étaient peut-être pas certaines des médicaments que le patient prenait à domicile ou que les médecins auraient pu laisser aux pharmaciens le soin de clarifier les doses. CONCLUSIONS: La description des médicaments administrés au moyen d'inhalateurs au moment de l'admission, figurant sur les formulaires du bilan comparatif des médicaments remplis par les médecins résidents pour les patients en pédiatrie souffrant d'asthme, était souvent incomplète. De futures interventions sur l'amélioration de la qualité, y compris les instructions données au patient et au résident, sont nécessaires dans l'institution où s'est déroulée l'étude. Il est probable que la collaboration avec les services de pharmacie améliorerait l'exhaustivité du processus du bilan comparatif des médicaments.

Canadian medical schools' preclerkship paediatric clinical skills curricula: How can we improve?

BACKGROUND: Little is known about how Canadian medical schools teach paediatric clinical skills (history and physical exam) to preclerkship students, or its cost to the institutions. METHODS: Clinical skills program directors from all 17 Canadian medical schools were contacted to complete a questionnaire focused on teaching methods, and barriers/strengths of their Preclerkship Paediatric Clinical Skills program. RESULTS: Seventeen schools (100% response rate) participated. Seven schools (41%) do not introduce paediatric clinical skills until the second year of medicine. Half of the schools (53%) dedicate <10 total hours to preclerkship paediatric clinical skills. Fifty-nine per cent have ≤6 total hours of hands-on paediatric patient interaction (real or simulated). Medical students were least likely to be exposed to the infant age group (age 1 to 24 months). Twelve schools (71%) used simulated parent/child dyads. The most significant barriers identified by programs were limited time for sessions and patient availability. We describe one sample medical school's simulated parent/paediatric patient program where every student has hands-on learning with paediatric patients of all ages (program cost $938/student). DISCUSSION: This study is the first to summarize Canadian preclerkship paediatric clinical skills programs, among which there is great variability and commonly experienced barriers. Many students are not being exposed to all age groups of paediatric patients before their clerkship years. Medical schools can use this information to strengthen this important and challenging aspect of the curriculum, while being mindful of its fiscal implications.

Rate of Strabismus Detection on Digital Photographs Increases by Using Off-center Near Target.

PURPOSE: To increase the detection rate of strabismus on digital photographs, with the ultimate aim of developing a new automated strabismus detection algorithm. METHODS: In this prospective case series, the authors acquired digital face photographs of 409 children with manifest or latent strabismus, using a 14-million-pixel camera with CCD image sensor. Of the last 52 enrolled, 34 image sets were selected for this study: 29 with manifest and 5 with latent strabismus. Images were taken at a distance of 40 to 70 cm in primary position, with the camera lens as the fixation target and in slight off-center fixation, and using a novel target of small light-emitting diodes mounted onto the camera case. The location of the corneal light reflection was manually calculated in relation to the center of the pupil in both eyes and ocular deviation as the difference in corneal light reflection location between the two eyes. In orthotropia, the expected deviation is zero. RESULTS: In children with phorias, the mean corneal light reflection location difference between the eyes was -0.10 ± 0.14 mm in primary position and -2.02 ± 0.39 mm in off-center fixation. Using a threshold of ±0.5 mm on either side of zero for central and of 2 mm for off-center fixation, sensitivity to detect strabismus increased from 65.6% in central to 79.3% in off-center fixation, respectively. The calculation of specificity will require inclusion of a population of individuals without strabismus. CONCLUSIONS: Off-center fixation onto a near target ensures that participants are actively looking at the target and may increase accommodative effort, thereby increasing the detection rate of strabismus. [J Pediatr Ophthalmol Strabismus. 2017;54(2):90-96.].

Improved A1C Levels in Type 1 Diabetes with Smartphone App Use.

OBJECTIVES: Smartphones are a potentially useful tool in diabetes care. We have developed an application (app) linked to a website, Intelligent Diabetes Management (IDM), which serves as both an insulin bolus calculator and an electronic diabetes diary. We have prospectively studied whether patients using this app improved control of their glucose levels. METHODS: Patients with type 1 diabetes were recruited. There was a 4-week observation period, midway during which we offered to review the participants' records. The app was then downloaded and participants' diabetes regimens entered on the synchronized IDM website. At 2, 4, 8, 12 and 16 weeks of the active phase, their records were reviewed online, and feedback was provided electronically. The primary endpoint was change in levels of glycated hemoglobin (A1C). RESULTS: Of the 31 patients recruited, 18 completed the study. These 18 made 572±98 entries per person on the IDM system over the course of the study (≈5.1/day). Their ages were 40.0±13.9 years, the durations of their diabetes were 27.3±14.9 years and 44% used insulin pumps. The median A1C level fell from 8.1% (7.5 to 9.0, IQ range) to 7.8% (6.9 to 8.3; p<0.001). During the observation period, glucose records were reviewed for 50% of the participants. In the active phase, review of the glucose diaries took less time on the IDM website than using personal glucose records in the observation period, median 6 minutes (5 to 7.5 IQ range) vs. 10 minutes (7.5 to 10.5 IQ range; p<0.05). CONCLUSIONS: Our smartphone app enables online review of glucose records, requires less time for clinical staff and is associated with improved glucose control.

A retrospective study of surgically excised phaeochromocytomas in Newfoundland, Canada.

OBJECTIVE: A retrospective study detailing the circumstances surrounding diagnosis and treatment of pheochromocytomas with the associated genetic disorders. MATERIALS AND METHODS: All patients with surgically excised pheochromocytomas in the Health Sciences Center, St. John's, Newfoundland, Canada between January 2001 and December 2010 were retrospectively analyzed to determine associated familial syndromes, age, tumor size, symptomatology, and percentage of paragangliomas and bilateral pheochromocytomas. Pathology specimen reports, adrenalectomy lists and Meditech (electronic medical record) diagnostic codes provided a comprehensive database for this study. RESULTS: Twenty-four patients were studied; familial disorder patients comprised 42% (10/24). Average age at diagnosis was 57 among the sporadic and 34 in familial disorder groups (P = 0.006). Average tumor size was 4.5 cm in the sporadic group and 3 cm in the familial disorder group (P = 0.19). All atypical cases including bilateral or extra-adrenal tumors and malignancy occurred in familial disorder patients. CONCLUSIONS: The proportion of familial disorder patients (42%) was higher in this study than would be expected, likely a result of the relatively high incidence of hereditary autosomal dominant disorders within Newfoundland. Among familial disorder patients, the average younger age at diagnosis and the smaller tumor size suggest syndromic pheochromocytomas may develop earlier, however they are more likely to be diagnosed sooner due to biochemical surveillance testing in known genetic disorder patients. We also demonstrate a relatively high incidence of surgically resected pheochromocytomas of 4.679/million/year in Newfoundland.

Encouraging residents to seek feedback.

AIM: To explore resident and faculty perceptions of the feedback process, especially residents' feedback-seeking activities. METHODS: We conducted focus groups of faculty and residents exploring experiences in giving and receiving feedback, feedback-seeking, and suggestions to support feedback-seeking. Using qualitative methods and an iterative process, all authors analyzed the transcribed audiotapes to identify and confirm themes. RESULTS: Emerging themes fit a framework situating resident feedback-seeking as dependent on four central factors: (1) learning/workplace culture, (2) relationships, (3) purpose/quality of feedback, (4) emotional responses to feedback. Residents and faculty agreed on many supports and barriers to feedback-seeking. Strengthening the workplace/learning culture through longitudinal experiences, use of feedback forms and explicit expectations for residents to seek feedback, coupled with providing a sense of safety and adequate time for observation and providing feedback were suggested. Tensions between faculty and resident perceptions regarding feedback-seeking related to fear of being found deficient, the emotional costs related to corrective feedback and perceptions that completing clinical work is more valued than learning. CONCLUSION: Resident feedback-seeking is influenced by multiple factors requiring attention to both faculty and learner roles. Further study of specific influences and strategies to mitigate the tensions will inform how best to support residents in seeking feedback.

Care of patients with Parkinson's disease in the operating department.

As our elderly population increases, theatre staff are frequently presented with the challenges of caring for patients with co-morbidities who are undergoing surgery. This article aims to educate the reader about Parkinson's disease, and suggest interventions that perioperative practitioners may want to consider in order to improve the patient's experience in the operating department.