Persistently High Rates of Abdominal Computed Tomography Imaging Among Patients With Inflammatory Bowel Disease Who Present to the Emergency Department.

Background: Recent guidelines recommended judicious use of abdominal computed tomography (CT) in the emergency department (ED) for inflammatory bowel disease. Trends in CT utilization over the last decade, including since the implementation of these guidelines, remain unknown. Methods: We performed a single-centre, retrospective study between 2009 and 2018 to assess trends in CT utilization within 72 h of an ED encounter. Changes in the annual rates of CT imaging among adults with IBD were estimated by Poisson regression and CT findings by Cochran-Armitage or Cochran-Mantel Haenszel tests. Results: A total of 3000 abdominal CT studies were performed among 14,783 ED encounters. CT utilization increased annually by 2.7% in Crohn's disease (CD) (95% confidence interval [CI], 1.2 to 4.3; P = 0.0004), 4.2% in ulcerative colitis (UC) (95% CI, 1.7 to 6.7; P = 0.0009) and 6.3% in IBD unclassifiable (95% CI, 2.5 to 10.0; P = 0.0011). Among encounters with gastrointestinal symptoms, 60% with CD and 33% with UC underwent CT imaging in the final year of the study. Urgent CT findings (obstruction, phlegmon, abscess or perforation) and urgent penetrating findings alone (phlegmon, abscess or perforation) comprised 34% and 11% of CD findings, and 25% and 6% of UC findings, respectively. The CT findings remained stable overtime for both CD (P = 0.13) and UC (P = 0.17). Conclusion: Our study demonstrated persistently high rates of CT utilization among patients with IBD who presented to the ED over the last decade. Approximately one third of scans demonstrated urgent findings, with a minority demonstrating urgent penetrating findings. Future studies should aim to identify patients in whom CT imaging is most appropriate.

A pre-clerkship simulation-based procedural skills curriculum: decreasing anxiety and improving confidence of procedural skill performance.

INTRODUCTION: Pre-clerkship procedural skills training is not yet a standard across Canadian medical school curricula, resulting in limited exposure to procedures upon entering clerkship. While simulated skills training has been documented in the literature to improve performance in technical ability, anxiety and confidence have yet to be investigated despite their documented impact on performance and learning. This study therefore aims to evaluate the effect of pre-clerkship procedural skills training on medical student anxiety and confidence. METHODS: A procedural skills training program was designed based on an evidence-based near-peer, flipped classroom model of education. Ninety-two second-year medical students volunteered for the study. Fifty-six were randomized to the training group, and 36 were randomized to the control group. Students in the training group attended seven procedural skills tutorials over seven months. The control group represented the average medical school student without standardized procedural training. Student anxiety and confidence were assessed at the beginning and end of the program using the State Trait Anxiety Inventory and Confidence Questionnaires. RESULTS: Students who participated in the procedural skills program demonstrated greater reductions in their state anxiety and greater improvements in confidence compared to the control group. CONCLUSION: Longitudinal procedural skills training in the simulation setting has demonstrated improvements in anxiety and confidence among pre-clerkship medical students. These added benefits to training have the potential to ease medical students' transition into clerkship, while also contributing to a safer and more effective clinical experience. Therefore, future integration of standardized pre-clerkship procedural skills training within medical school curricula should be considered.

INTRODUCTION: Les cursus de pré-externat des facultés de médecine canadiennes ne prévoient pas systématiquement de formation sur les habiletés techniques avant, si bien qu'à leur arrivée à l'externat, les étudiants ont une exposition limitée aux gestes techniques. Tandis que l'amélioration des aptitudes techniques par la simulation est bien documentée, il n'y a aucune étude sur l'effet de ces simulations sur l'anxiété et la confiance malgré leur impact avéré sur la performance et l'apprentissage. Cette étude vise donc à évaluer l'effet d'une formation sur les habiletés techniques au pré-externat sur l'anxiété et la confiance des étudiants en médecine. MÉTHODES: Une formation sur les habiletés techniques a été conçue sur la base d'un modèle d'enseignement fondé sur les données probantes, par les quasi-pairs suivant une approche de classe inversée. Quatre-vingt-douze étudiants en deuxième année de médecine ont participé à l'étude sur une base volontaire. Cinquante-six d'entre eux ont été répartis au hasard dans le groupe qui devait recevoir la formation, et 36 dans le groupe contrôle. Les étudiants du groupe qui a reçu la formation ont assisté à sept tutoriels étalés sur une période de sept mois. Le groupe témoin représentait l'étudiant en médecine moyen sans formation normalisée axée sur les habiletés techniques. L'anxiété et la confiance des étudiants ont été évaluées au début et à la fin du programme à l'aide du questionnaire State Trait Anxiety Inventory (questionnaire sur l'anxiété chronique et réactionnelle) et d'un questionnaire sur la confiance. RÉSULTATS: Chez les étudiants qui ont participé au programme de formation sur les habiletés techniques, la baisse de l'anxiété et l'amélioration de la confiance en soi ont été plus importantes que chez les étudiants du groupe contrôle. CONCLUSION: La formation longitudinale axée sur les habiletés techniques en contexte de simulation a eu des effets positifs en ce qui concerne l'anxiété et la confiance chez les étudiants en médecine au pré-externat. La formation offre l'avantage supplémentaire de faciliter la transition des étudiants en médecine vers l'externat, tout en contribuant à rendre l'expérience clinique plus sûre et plus efficace. Il serait donc intéressant pour les facultés de médecine d'intégrer dans le cursus une formation normalisée axée sur les habiletés techniques au pré-externat.

SCN2A Pathogenic Variants and Epilepsy: Heterogeneous Clinical, Genetic and Diagnostic Features.

Pathogenic variants of the SCN2A gene (MIM 182390) are associated with several epileptic syndromes ranging from benign familial neonatal-infantile seizures (BFNIS) to early infantile epileptic encephalopathy. The aim of this work was to describe clinical features among five patients with concomitant SCN2A gene variants and cryptogenic epileptic syndromes, thus expanding the SCN2A spectrum of phenotypic heterogeneity. De novo variants were identified in four patients, while one inherited variant was identified in a patient with an unaffected carrier biological father with somatic mosaicism. Two of five patients were diagnosed with a neonatal epileptic encephalopathy. The remaining three patients manifested a focal epileptic syndrome associated with autistic spectrum disorders (ASD) or with a variable degree of intellectual disability (ID), one of them displaying a hitherto unreported atypical late onset epilepsy. Overall, the pattern of clinical manifestations among these patients suggest that any observed neurological impairment may not be directly related to the severity of the electroclinical pattern, but instead likely associated with the mutation itself. Moreover, our results highlight the importance of SCN2A mutational screening in cases of ID/ASD with or without epilepsy.

Identifying essential procedural skills in Canadian undergraduate medical education.

INTRODUCTION: We conducted a national survey to characterize current Canadian procedural skills training in Undergraduate Medical Education (UGME). The goals were to identify the most important procedures students should know upon graduation and assess clinician-educator perceptions regarding implementation of a pre-clerkship procedural program. METHODS: We distributed the survey to physician-educators across Canada's 17 medical schools. Respondents were directed to an individualized survey that collected demographic data, physician-educator responses on essential procedural skills, as well as physician-educator opinions on the value of a pre-clerkship procedural training program. RESULTS: The response rate for this survey was 21% (42 out of 201 distributed surveys were completed). The top 10 most important procedures identified by physician-educators included IV Access, Airway Management, Local anesthesia/field block, Casting, Spontaneous Vaginal Delivery, Testing for STIs, Phlebotomy, Suturing of Lacerations, Nasogastric Tube Insertion, and Venipuncture. Physician-educators supported a pre-clerkship procedural program. CONCLUSIONS: Identifying the most crucial procedural skills is the first step in implementing a competency-based procedural skills training program for Canadian medical students. With the list of essential skills, and the support for physician-educators in developing a pre-clerkship procedural skills curriculum, hopefully there can be future development of formalized curricula.

CONTEXTE: Nous avons mené un sondage à l'échelle nationale pour caractériser les compétences procédurales canadiennes dans la formation médicale de premier cycle. L'objectif était de reconnaître les plus importantes procédures que les étudiants devaient connaître à la fin de leur formation et d'évaluer les perceptions des cliniciens éducateurs au sujet de la mise en œuvre de leur programme procédural avant les stages. MÉTHODES: Nous avons distribué le sondage à des médecins éducateurs dans les 17 écoles de médecine du Canada. Les répondants ont été dirigés vers un sondage individualisé qui recueillait les données démographiques, les réponses des médecins éducateurs sur les compétences procédurales essentielles, ainsi que les opinions des médecins éducateurs sur la valeur du programme de formation procédurale avant les stages. RÉSULTATS: Le taux de réponse à ce sondage a été de 21 % (42 des 201 sondages distribués ont été remplis). Les dix plus importantes procédures recensées par les médecins éducateurs comprenaient l'accès IV, l'assistance respiratoire, le bloc anesthésie locale/champ, le moulage de plâtre, l'accouchement spontané par voie vaginale, les tests d'ITS, la phlébotomie, la suture des lacérations, l'insertion d'une sonde nasogastrique et la ponction veineuse. Les médecins éducateurs soutenaient un programme procédural avant les stages. CONCLUSIONS: Établir les compétences procédurales les plus essentielles représente la première étape dans la mise en œuvre d'un programme de formation dans les compétences procédurales fondé sur les compétences pour les étudiants canadiens en médecine. Avec la liste de compétences essentielles et le soutien des médecins éducateurs dans le développement d'un programme de compétences procédurales avant les stages, nous espérons qu'un programme structuré sera élaboré.

Monitoring adherence to guidelines of antibiotic use in pediatric pneumonia: the MAREA study.

BACKGROUND: Children are the most vulnerable population exposed to the use of antibiotics often incorrectly prescribed for the treatment of infections really due to viruses rather than to bacteria. We designed the MAREA study which consisted of two different studies: i) a surveillance study to monitor the safety/efficacy of the antibiotics for the treatment of pneumonia (CAP), pharyngotonsillitis and acute otitis media in children younger than 14 yrs old, living in Liguria, North-West Italy and ii) a pre-/post-interventional study to evaluate the appropriateness of antibiotic prescription for the treatment these infections. In this paper, we show only results of the appropriateness study about the antibiotic prescription for the treatment of pneumonia. METHODS: Patients included in this study met the following inclusion criteria: i) admission to the Emergency/Inpatient Dpt/outpatient clinic of primary care pediatricians for pneumonia requiring antibiotics, ii) informed written consent. The practice of prescribing antibiotics was evaluated before-and-after a 1 day-educational intervention on International/National recommendations. RESULTS: Global adherence to guidelines was fulfilled in 45%: main reason for discordance was duration (shorter than recommended). Macrolide monotherapy and cephalosporins were highly prescribed; ampicillin/amoxicillin use was limited. 61% of patients received >1 antibiotic; parenteral route was used in 33%. After intervention, i) in all CAP, cephalosporin prescription decreased (-23%) and the inappropriate macrolide prescriptions was halved and, ii) in not hospitalized CAP (notH-CAP), macrolides were prescribed less frequently (-25%) and global adherence to guidelines improved (+39%); and iii) in H-CAP antibiotic choice appropriateness increase. CONCLUSION: Prescribing practices were sufficiently appropriate but widespread preference for multidrug empirical regimens or macrolide in monotherapy deserve closer investigation.

Cigarette Smoke Attenuates the Nasal Host Response to Streptococcus pneumoniae and Predisposes to Invasive Pneumococcal Disease in Mice.

Streptococcus pneumoniae is a leading cause of invasive bacterial infections, with nasal colonization an important first step in disease. While cigarette smoking is a strong risk factor for invasive pneumococcal disease, the underlying mechanisms remain unknown. This is partly due to a lack of clinically relevant animal models investigating nasal pneumococcal colonization in the context of cigarette smoke exposure. We present a model of nasal pneumococcal colonization in cigarette smoke-exposed mice and document, for the first time, that cigarette smoke predisposes to invasive pneumococcal infection and mortality in an animal model. Cigarette smoke increased the risk of bacteremia and meningitis without prior lung infection. Mechanistically, deficiency in interleukin 1α (IL-1α) or platelet-activating factor receptor (PAFR), an important host receptor thought to bind and facilitate pneumococcal invasiveness, did not rescue cigarette smoke-exposed mice from invasive pneumococcal disease. Importantly, we observed cigarette smoke to attenuate nasal inflammatory mediator expression, particularly that of neutrophil-recruiting chemokines, normally elicited by pneumococcal colonization. Smoking cessation during nasal pneumococcal colonization rescued nasal neutrophil recruitment and prevented invasive disease in mice. We propose that cigarette smoke predisposes to invasive pneumococcal disease by suppressing inflammatory processes of the upper respiratory tract. Given that smoking prevalence remains high worldwide, these findings are relevant to the continued efforts to reduce the invasive pneumococcal disease burden.