Integrating the social determinants of health into curriculum: AMEE Guide No. 162.

The World Health Organization (WHO) defines the Social Determinants of Health (SDOH) as the non-medical factors influencing health outcomes. SDOH is associated with conditions in which people are born, grow, work, and live. Medical schools and licensing bodies are increasingly recognizing the need for doctors and healthcare professionals to be aware of their patient's social context and how it impacts their states of health and disease. However, there is considerable variation in the approaches of different institutions and countries to incorporating SDOH into their curricula. In order to allow clinicians to adopt a holistic approach to patient health, equipping them with extensive knowledge of SDOH would give learners the confidence, skills, knowledge, and attitudes needed to effectively engage with patients and their families. This approach aids health professionals with knowledge of the influence of the social context and cultural factors that affect patients' behaviors in relation to health. Incorporating the SDOH in medical and health professional school curricula would contribute towards adequately preparing future healthcare practitioners to provide effective, comprehensive, and equitable care, especially to marginalized and underserved populations. The Guide will take an evidence-based approach grounded in the available contemporary literature and case studies. The focus will be on integrating SDOH into undergraduate and postgraduate medical curricula to promote an understanding of the social factors that influence patients' and communities' health. Ultimately, this guide seeks to contribute to the reduction of inequalities in health.

Unmasking a New Type of Gastrointestinal Foreign Body in the COVID-19 Era.

The incidence of foreign body ingestion has increased during the coronavirus disease 2019 pandemic. As face masks became increasingly available, we report a case of accidental ingestion of the metal strip insert of a surgical mask. After initially progressing, its progress halted after 24 hours. This case highlights the challenges of timing the endoscopic removal of long objects, especially considering the reduced endoscopic availability during the pandemic. Despite only causing local trauma, the strip was impacted at the duodenojejunal flexure with the potential to cause obstruction. Limiting morbidity relies on urgent removal and prevention of similar ingestions by emphasizing the safe use and storage of masks.

Case report: Drug reaction with eosinophilia and systemic symptoms (DRESS)-induced hemophagocytic disorder.

Hemophagocytic disorders are severe and life-threatening conditions that can be genetic in origin [i.e., primary hemophagocytic lymphohistiocytosis (HLH)] or result from infections (i.e., secondary hemophagocytic lymphohistiocytosis), rheumatologic disease [i.e., macrophage activation syndrome (MAS)], and less frequently immunodeficiency or metabolic disease. Although rare, drug-induced hemophagocytosis needs to be considered in the work-up as it requires specific management strategies. Most drug-induced hemophagocytic disorders are related to Drug Reaction with Eosinophilia and Systemic Symptoms (DRESS). We present the case of a 7-year-old girl who initially presented with fever, maculopapular rash, and unilateral lymphadenopathy, who went on to develop hemophagocytosis secondary to DRESS caused by prolonged combination treatment with amoxicillin/clavulanic acid and trimethoprim/sulfamethoxazole. This case illustrates the importance of considering adverse drug reactions in the evaluations of patients with a hemophagocytic process.

Creating a student-led health magazine with an urban, multicultural, resource-restricted elementary school: Approach, process and impact.

BACKGROUND: Health magazines effectively deliver health information. No data regarding student-led magazines to promote health exist. OBJECTIVE: To evaluate whether children's health knowledge, interests and lifestyle choices improve following distribution of a student-led health magazine. METHODS: Elementary students worked with teachers and paediatric residents to publish a health magazine. A healthy lifestyle challenge page promoted reduction in soda pop consumption. Pre- and poststudent questionnaires explored knowledge, interests and behaviours related to health. RESULTS: Sex and grade distributions were similar in pre- and post-questionnaires. Ninety-seven percent of children reported the magazine helped them learn about health. Pre- and postknowledge scores did not differ (P=0.36). Following distribution, the percentage of students who reported drinking no soda increased from 43% to 67% (P=0.004), and those who reported drinking <2 glasses of soda per day increased from 66% to 85% (P=0.01). CONCLUSIONS: A student-led health magazine was effective in motivating short-term student-reported behavioural change.

HISTORIQUE: Les magazines sur la santé transmettent avec efficacité de l'information en matière de santé. Il n'existe aucune donnée relative aux magazines dirigés par des élèves pour promouvoir la santé. OBJECTIF: Évaluer si les connaissances des enfants en matière de santé, leurs intérêts et leurs choix de vie s'améliorent après la distribution d'un magazine sur la santé dirigé par des élèves. MÉTHODOLOGIE: Aidés de leurs enseignants et de résidents en pédiatrie, des élèves du primaire ont publié un magazine sur la santé. Une page présentant un défi santé incitait les élèves à réduire leur consommation de boissons gazeuses. Les questionnaires remplis avant et après la distribution du magazine évaluaient les connaissances, les intérêts et les comportements liés à la santé. RÉSULTATS: La répartition selon le sexe et le degré scolaire était similaire dans les questionnaires avant et après la distribution du magazine. De plus, 97 % des enfants ont déclaré que le magazine les avait aidés à acquérir des connaissances sur la santé. Les scores de connaissances avant et après la distribution du questionnaire n'ont pas changé (P=0,36). Après la distribution, le pourcentage d'élèves qui déclaraient ne pas boire de boissons gazeuses est passé de 43 % à 67 % (P=0,004), et ceux qui déclaraient en boire moins de deux verres par jour est passé de 66 % à 85 % (P=0,01). CONCLUSIONS: Un magazine sur la santé dirigé par des élèves a réussi à motiver un changement à court terme dans le comportement déclaré des élèves.

Evaluation of a social pediatrics elective: transforming students' perspective through reflection.

OBJECTIVE: The aim of this study was to examine aspects of a social pediatrics elective that led to student self-reflection and transformation. METHODS: To assess student learning from our social pediatric elective, we retrospectively evaluated self-reflection papers. We focused on the effectiveness of the educational approach to inspire students to incorporate the social determinants of health into their practice. Furthermore, in each reflection paper, we looked for evidence of different phases of transformation. RESULTS: The social determinants of health were the most commonly described theme. Poverty was mentioned directly or described implicitly in almost all papers. For many students, seeing the social context of patients in real life, whether in a special clinic or at a home visit, was a disturbing and disorienting experience that triggered transformation. CONCLUSION: The use of reflection papers in the evaluation of a social pediatric elective documented transformative learning.

A qualitative description of the development and evaluation of our voice, a health promotion magazine created by pediatric patients for hospitalized pediatric patients.

OBJECTIVES: To facilitate a peer-developed health promotion magazine that provides health education and engages hospitalized pediatric patients during a hospital admission. To evaluate patient satisfaction with the content and layout of the magazine and its impact on patients' attitudes toward healthy living. METHODS: A pediatric resident-led multidisciplinary team collaborated with the Children's Council at The Hospital for Sick Children to create a health promotion magazine for inpatients. Articles included a scavenger hunt, healthy recipes, physical activities, hospital staff interviews, and patient stories. Patients 7 to 18 years of age admitted to Pediatric Medicine or Respirology were invited to read the magazine and complete a questionnaire 24 hours later on their satisfaction with the magazine and their attitudes regarding healthy living. RESULTS: Thirty-seven patients received a copy of the magazine, and 24 patients completed the questionnaire (mean 13.4 years, 54% female, 25% overweight/obese). Eleven of 24 (46%) read the entire magazine, and 19 of 23 (83%) reported learning. The exercises, recipes, and patient stories were most liked. Ten of 24 (42%) participants performed the exercises; the most common reason for not trying an exercise was pain. After reading the magazine, 15 of 24 (65%) patients reported that they will try to be more active, and 11 of 23 (48%) reported that they will try to eat more fruits and vegetables. Eighty-three percent were interested in a future edition. CONCLUSIONS: A health promotion magazine created by patients for patients changed patient-reported attitudes about healthy living. Peer-led interventions in the inpatient setting may be an important opportunity to promote healthy lifestyles and require further study.

Delayed identification of pediatric abuse-related fractures.

OBJECTIVES: Because physicians may have difficulty distinguishing accidental fractures from those that are caused by abuse, abusive fractures may be at risk for delayed recognition; therefore, the primary objective of this study was to determine how frequently abusive fractures were missed by physicians during previous examinations. A secondary objective was to determine clinical predictors that are associated with unrecognized abuse. METHODS: Children who were younger than 3 years and presented to a large academic children's hospital from January 1993 to December 2007 and received a diagnosis of abusive fractures by a multidisciplinary child protective team were included in this retrospective review. The main outcome measures included the proportion of children who had abusive fractures and had at least 1 previous physician visit with diagnosis of abuse not identified and predictors that were independently associated with missed abuse. RESULTS: Of 258 patients with abusive fractures, 54 (20.9%) had at least 1 previous physician visit at which abuse was missed. The median time to correct diagnosis from the first visit was 8 days (minimum: 1; maximum: 160). Independent predictors of missed abuse were male gender, extremity versus axially located fracture, and presentation to a primary care setting versus pediatric emergency department or to a general versus pediatric emergency department. CONCLUSIONS: One fifth of children with abuse-related fractures are missed during the initial medical visit. In particular, boys who present to a primary care or a general emergency department setting with an extremity fracture are at a particularly high risk for delayed diagnosis.

Residents as health advocates: The development, implementation and evaluation of a child advocacy initiative at the University of Toronto (Toronto, Ontario).

BACKGROUND AND OBJECTIVE: Advocacy is an integral part of a paediatrician's role. The Royal College of Physicians and Surgeons of Canada has identified advocacy as one of the essential Canadian Medical Education Directives for Specialists competencies, and participation in child advocacy work as an important component of paediatric residency training. The objective of the present paper was to describe the development, implementation and evaluation of the first four years of the child advocacy initiative at the University of Toronto (Toronto, Ontario). METHODOLOGY: Ideas for community child advocacy projects were generated through a literature review, and a link to a local elementary school was identified. Teacher and parent focus groups were conducted to identify areas for resident involvement. Workshops were then developed, implemented and evaluated by paediatric residents. RESULTS: Six child advocacy projects between 2001 and 2004 were conducted based on results from the focus groups. These included annual clothing drives, as well as workshops for parents and children about nutrition, safety, parenting, illness management and basic first aid. More than 95% of parents reported that the workshops were useful or very useful, more than 92% felt that they learned something new and more than 83% wanted the residents to return for further workshops. Teachers and residents gave positive informal feedback. CONCLUSIONS: Through the child advocacy initiative, paediatric residents had the opportunity to develop skills in advocacy, learn about the determinants of child health and become community partners in advocating for children. Such an initiative can be incorporated into the residency curriculum to help residents develop competency in advocacy.