Severe Pediatric COVID-19 and Multisystem Inflammatory Syndrome in Children From Wild-type to Population Immunity: A Prospective Multicenter Cohort Study With Real-time Reporting.

BACKGROUND: SARS-CoV-2 variant evolution and increasing immunity altered the impact of pediatric SARS-CoV-2 infection. Public health decision-making relies on accurate and timely reporting of clinical data. METHODS: This international hospital-based multicenter, prospective cohort study with real-time reporting was active from March 2020 to December 2022. We evaluated longitudinal incident rates and risk factors for disease severity. RESULTS: We included 564 hospitalized children with acute COVID-19 (n = 375) or multisystem inflammatory syndrome in children (n = 189) from the Netherlands, Curaçao and Surinam. In COVID-19, 134/375 patients (36%) needed supplemental oxygen therapy and 35 (9.3%) required intensive care treatment. Age above 12 years and preexisting pulmonary conditions were predictors for severe COVID-19. During omicron, hospitalized children had milder disease. During population immunity, the incidence rate of pediatric COVID-19 infection declined for older children but was stable for children below 1 year. The incidence rate of multisystem inflammatory syndrome in children was highest during the delta wave and has decreased rapidly since omicron emerged. Real-time reporting of our data impacted national pediatric SARS-CoV-2 vaccination- and booster-policies. CONCLUSIONS: Our data supports the notion that similar to adults, prior immunity protects against severe sequelae of SARS-CoV-2 infections in children. Real-time reporting of accurate and high-quality data is feasible and impacts clinical and public health decision-making. The reporting framework of our consortium is readily accessible for future SARS-CoV-2 waves and other emerging infections.

Sildenafil Citrate Overdose in a 3-Month Postterm Premature Infant With Pulmonary Artery Hypertension.

OBJECTIVE: We aimed to describe a case of prematurely born infant with accidental sildenafil overdose. METHODS: This was a retrospective case report followed with chart and literature review. MAIN FINDINGS: A prematurely born infant with moderate bronchopulmonary dysplasia, corrected congenital heart disease, and pulmonary hypertension presented with an accidental sildenafil overdose. Despite the relatively high dose in this medically frail infant and the long elimination half-life of sildenafil in infants, the symptoms of sildenafil overdose in our patient were only mild. After a short and uneventful period of observation in the hospital, the patient was discharged home. CONCLUSIONS: Sildenafil overdose can cause serious symptoms such as hypotension. However, in our case, the sildenafil overdose was well tolerated, even by a young patient with underlying heart and lung disease. We show that choices in the management of sildenafil intoxication can be made based on the knowledge of sildenafil pharmacokinetics in young children.

A pharmacotherapy self-assessment improves prescribing by prompting junior doctors to study further.

AIMS: Junior doctors frequently prescribe incorrectly and this can cause serious harm to patients. Pharmacotherapy education in most medical schools falls short in preparing their students to prescribe safely in clinical practice. According to the theory of assessment-driven learning, a pharmacotherapy self-assessment for junior doctors may reduce potential harmful prescriptions in clinical practice, by revealing deficits in prescribing knowledge and skills. METHODS: In this single centre, prospective cohort study, the potential harmful prescriptions of junior doctors in clinical practice were compared before and after a pharmacotherapy self-assessment with and without additional pharmacotherapy education. RESULTS: Potential harmful prescriptions best known to cause harm to patients were studied in all the prescriptions written out by 199 junior doctors in the first 2 months of their employment in our hospital. The pharmacotherapy self-assessment reduced the total number of potential harmful prescriptions made by junior doctors relative to those made by junior doctors in the control group (1.3 vs. 3.2%, respectively; P < .001). Additional education did not reduce potential harmful prescriptions beyond the effect of the self-assessment alone (1.3 vs. 1.0%, P > .05). CONCLUSIONS: Pharmacotherapy self-assessment leads to fewer potential harmful prescriptions made by junior doctors in clinical practice, thereby improving patient safety. More research is needed to investigate whether additional pharmacotherapy education strategies reduce potential harmful prescriptions further.

Barriers and Facilitators When Implementing Web-Based Disease Monitoring and Management as a Substitution for Regular Outpatient Care in Pediatric Asthma: Qualitative Survey Study.

BACKGROUND: Despite their potential benefits, many electronic health (eHealth) innovations evaluated in major studies fail to integrate into organizational routines, and the implementation of these innovations remains problematic. OBJECTIVE: The purpose of this study was to describe health care professionals' self-identified perceived barriers and facilitators for the implementation of a Web-based portal to monitor asthmatic children as a substitution for routine outpatient care. Also, we assessed patients' (or their parents) satisfaction with this eHealth innovation. METHODS: Between April and November 2015, we recruited 76 health care professionals (from 14 hospitals). During a period of 6 months, participants received 3 questionnaires to identify factors that facilitated or impeded the use of this eHealth innovation. Questionnaires for patients (or parents) were completed after the 6-month virtual asthma clinic (VAC) implementation period. RESULTS: Major perceived barriers included concerns about the lack of structural financial reimbursement for Web-based monitoring, lack of integration of this eHealth innovation with electronic medical records, the burden of Web-based portal use on clinician workload, and altered patient-professional relationship (due to fewer face-to-face contacts). Major perceived facilitators included enthusiastic and active initiators, a positive attitude of professionals toward eHealth, the possibility to tailor care to individual patients ("personalized eHealth"), easily deliverable care according to current guidelines using the VAC, and long-term profit and efficiency. CONCLUSIONS: The implementation of Web-based disease monitoring and management in children is complex and dynamic and is influenced by multiple factors at the levels of the innovation itself, individual professionals, patients, social context, organizational context, and economic and political context. Understanding and defining the barriers and facilitators that influence the context is crucial for the successful implementation and sustainability of eHealth innovations.

Instructiveness of real patients and simulated patients in undergraduate medical education: a randomized experiment.

PURPOSE: Few studies have compared the instructiveness of real patient contacts with simulated patient (SP) contacts. Although most of these studies found no difference, students often comment that the instructiveness of both encounters is dissimilar. The aims of this study were to evaluate which contact (real patient or SP) is perceived as most instructive by students and which variables contribute to this. METHOD: The authors performed an experiment involving 163 first-year medical students, randomized to having a real patient contact (n = 61) or SP contact (n = 102). Quantitative (questionnaires) and qualitative (focus groups) methods were used to evaluate the perceived instructiveness of the contact. RESULTS: The general instructiveness of both real patient contacts and SP contacts was marked high. Several differences between the evaluations of real patient contacts and SP contacts were found. For example, students considered real patient contacts less helpful in practicing communication skills and considered the real patients' feedback less relevant. The focus group interviews yielded explanations for many of the differences found. Students regarded real patients as more authentic. However, SPs were better informed about the purpose of the consultation and provided the student with more specific feedback. CONCLUSIONS: Students consider authenticity an important advantage of real patients. Their difficult recruitment is an important disadvantage, however, SPs have important advantages compared with real patients--for example, their feedback. The choice of real patient contacts or SP contacts for medical education depends on factors like the phase of the curriculum and the aim of the encounter.

The case of "Miss Jacobs": adolescent simulated patients and the quality of their role playing, feedback, and personal impact.

OBJECTIVE: Adolescents as standardized patients are relatively new in medical education. Studies have mostly explored the impact of role playing on adolescents trained to perform standardized patient roles for assessment purposes. No studies were found with regard to the quality of adolescents' role playing. We evaluated the effects of performing a patient role on adolescents trained as simulated patients (SPs) for teaching purposes (in contrast to standardized patients) and evaluated the quality of adolescent SPs' role playing and feedback. METHODS: Nine young women, aged 16 to 18 years, were trained to portray roles of adolescents asking their general practitioner for an oral contraceptive. Three adolescent men were trained to portray roles of some of the girls' boyfriends. Each role was developed in consultation with the individual adolescent and was largely based on her own personal experience. Students rated the quality of the adolescent SP's role playing and feedback after each SP encounter on a previously validated questionnaire (the Maastricht Assessment of Simulated Patients). Both the adolescent SPs and faculty teachers both completed questionnaires on their experiences. RESULTS: Three hundred forty-one students rated the quality of the SPs' role playing and feedback with a mean score of 7.5 of 10. The faculty teachers were also generally positive about the role playing and feedback. Nevertheless, there were some concerns about the quality of the feedback. Adolescent SPs reported no negative effects because of their performance. CONCLUSION: Generally, students and teachers were satisfied with the quality of the role playing and feedback provided by the adolescent SPs. The adolescent SPs experienced no negative effects related to their performance, which confirms earlier findings among adolescent standardized patients.

Students' views on the use of real patients and simulated patients in undergraduate medical education.

PURPOSE: To determine students' views about the strengths and weaknesses of real patient interactions as opposed to simulated patient (SP) interactions in the undergraduate medical curriculum in order to evaluate how their strengths can be optimally used and weaknesses remedied. METHOD: Five focus-group interviews were conducted among fourth- and fifth-year medical students at Maastricht University in 2007, using a preestablished interview guide. The interviews were recorded, transcribed, and analyzed using qualitative methods. RESULTS: In general, the 38 participants considered real patient encounters more instructive and more authentic than SP encounters. However, students identified several strengths of SP encounters compared with real patient encounters. For example, SP interactions were helpful in preparing students for real patient interactions (particularly with regard to communication skills and self-confidence), in the teaching of "intimate" physical examination skills, such as gynecological examination skills, and in giving constructive feedback on communication skills. In contrast to what we had anticipated, taking a time-out was considered easier in real patient interactions. CONCLUSIONS: Both real patient interactions and SP interactions are considered indispensable to undergraduate medical education. Each encounter has unique strengths and weaknesses from the perspectives of students. On the basis of strengths and weaknesses that were identified, suggestions were made for the use of real patients and SPs in undergraduate medical education.

Feedback by simulated patients in undergraduate medical education: a systematic review of the literature.

OBJECTIVES: Although the importance of feedback by simulated patients (SPs) is generally recognised, knowledge is scarce about the most effective ways in which SPs can provide feedback. In addition, little is known about how SPs are trained to provide feedback. This study aimed to provide a systematic overview of the ways in which SPs provide feedback to undergraduate medical students, the domains in which SPs provide feedback and the ways in which SPs are trained to provide feedback. METHODS: We performed a systematic search of the literature using PubMed, PsychINFO and ERIC and searched for additional papers cited in reference lists. Papers were selected on the basis of pre-established inclusion and exclusion criteria and were classified, using a pre-established form, according to three aspects of SP feedback: training in giving feedback; the process of delivering feedback, and the domain(s) in which feedback is given. RESULTS: A total of 49 studies were included and described in detail on the basis of the three aspects of SP feedback described above. The ways in which SPs were trained to give feedback were largely heterogeneous, as were the processes by which feedback was provided by SPs. Only a few studies described feedback processes that were in accordance with general recommendations for the delivery of effective feedback. Although feedback from the patient's perspective is generally recommended, most SPs provided feedback on clinical skills and communication skills. DISCUSSION: There appear to be no clear standards with regard to effective feedback training for SPs. Furthermore, the processes by which feedback is provided by SPs and the selection of domain(s) in which SPs give feedback often seem to lack a solid scientific basis. Suggestions for further research are provided.

Lessons learned from an adolescent simulated patient educational program: Five years of experience.

BACKGROUND: The use of adolescents as standardized patients (SPs) in medical education has scarcely been reported. We evaluated the views of teachers, students and adolescent SPs with regard to the adolescent SP program in our under graduate curriculum and the changes that were made to the program in the past five years (from 2002-2003 until 2006-2007). METHOD: Adolescent girls were recruited to portray roles of adolescents asking their general practitioner for an oral contraceptive.Students rated the quality of the adolescent SPs? role performance and feedback on a validated questionnaire (the MaSP). Both adolescent SPs and faculty teachers completed questionnaires on their experiences. RESULTS: Over the past five years, 201 to 341 students gave the adolescent SPs? general performance a mean mark that varied from 7.5 to 8 out of 10. Generally, evaluations by teachers and adolescent SPs about the adolescent SP program were also very positive.The quality of the feedback by adolescent SPs has shown improvement over the past five years, although adolescents find it quite difficult to give feedback. CONCLUSIONS: Teachers, students and adolescent SPs have highly valued the adolescent SP program over the past five years.The program has been changed on the basis of the lessons learned and has become mature.

The longitudinal simulated patient program: evaluations by teachers and students and feasibility.

OBJECTIVE: Simulated patients (SPs) are mostly used in single-case encounters. However, for chronic care training longitudinal patient encounters are more suitable. Evaluations of students and teachers regarding a new, longitudinal SP program were explored and compared to the single-case SP program. Furthermore, the feasibility of the program was explored. METHODS: Year 3 students participating in the longitudinal SP program (N=272) had four encounters with the same SP portraying a chronic health problem in eight months. Student evaluations regarding the longitudinal SP program were assessed with a validated questionnaire (the MaSP) and both teachers and students completed another questionnaire on their views. RESULTS: In general, students and teachers were positive about the longitudinal SP program. We found no differences between student evaluations regarding the longitudinal SP program and those regarding the single-case SP program. The longitudinal SP program appeared not to be feasible because of uncooperative faculty staff and the workload. CONCLUSIONS: Students consider the longitudinal SP program as good as the single-case SP program. In its current form the longitudinal SP program appeared not to be feasible. Further research is needed in our search for an instructive, enjoyable and feasible SP program to teach students about continuity of care.

Strengths and weaknesses of simulated and real patients in the teaching of skills to medical students: a review.

The aim of this review was to identify the strengths and weaknesses of the roles of real and simulated patients in undergraduate medical education. The literature was reviewed in relation to four patient roles: real patients as educational "resource" (passive role), real patients as teachers (active role), and simulated patients as educational resource and teachers. Each of the four patient roles was found to have specific advantages and disadvantages from the perspectives of teachers, students, and patients. For example, advantages of real patients as educational resource were patient-centered learning and high patient satisfaction. Disadvantages were their limited availability and the variability in learning experiences among students. Despite the considerable amount of literature we found, many gaps in knowledge about patient roles in medical education remain and should be addressed by future studies.

Unannounced standardised patients in real practice: a systematic literature review.

BACKGROUND: No attempt has been made to give a systematic overview of the innovative use of unannounced or incognito standardised patients. OBJECTIVE: To provide a systematic overview of all published studies with incognito standardised patients assessing doctors in actual practice situations using sound reliable and valid standardised patient methodology. METHODS: Systematic literature search in Medline, Eric and Psyclit with piloted search terms, followed by retrieving additional papers from reference lists. All papers were scored with a predefined protocol-sheet using predefined inclusion and exclusion criteria. RESULTS: Forty papers referring to 21 projects with incognito standardised patients were found and described in detail. The majority of studies were conducted in primary care and were descriptive. DISCUSSION: There is a need for research on the additional value of the incognito standardised patient methodology and for a consensus on how to report on accuracy and consistency of standardised patients.

The impact of simulation on people who act as simulated patients: a focus group study.

OBJECTIVE: Previous studies have shown that people who act as simulated patients (SPs) experience negative effects caused by performing patient roles. This study was performed to further explore the impact of simulation and the factors that might affect this impact. The aim was to find ways of preventing negative effects of simulation impacting on our SPs. METHODS: Focus groups interviews were conducted among 35 SPs at Skillslab, University of Maastricht. The discussion was guided by 6 pre-established items. RESULTS: The majority of the SPs appeared to experience negative effects of performing a patient role. The effects were considered as inherent to acting as an SP or due to simulation being a strenuous activity. The impact was short-lived and did not affect SPs' enjoyment of their work. Factors that appeared to affect the impact of performing included: the type of role (whether it is emotionally complex or not); the number of consecutive performances; the length of time between performances; the giving of feedback; the amount of experience, and students. DISCUSSION: Although the SPs were found to experience negative effects caused by playing patient roles, the frequency and intensity of the negative effects were minor. The focus group discussions led to various suggestions for measures to reduce the impact of simulation.

Performance-related stress symptoms in simulated patients.

INTRODUCTION: During the first 4 years of the 6-year undergraduate medical curriculum at Maastricht University, the Netherlands, students practise clinical skills in simulated patient (SP) encounters at the Skillslab. Generally, these encounters are instructive and enjoyable for both students and SPs. However, in conversations with SP trainers, some SPs have mentioned experiencing adverse symptoms due to performing a patient role. Some published studies have reported similar findings in SPs. We explored the seriousness of this problem by surveying SPs on the occurrence and severity of stress symptoms related to performing patient roles. We also examined by which variables the symptoms were influenced. METHODS: An anonymous questionnaire was developed to investigate factors related to stress symptoms and the frequency and severity of stress symptoms. A burnout scale was also included in the questionnaire. All SPs who had performed between March 2000 and March 2001 were asked to participate. RESULTS: The response rate was 84%. Of the SPs, 73% were found to have experienced stress symptoms, with a mean of 4 symptoms per SP. No significant correlations were found between the occurrence of symptoms on the one hand and factors that might influence symptoms or the burnout scale on the other hand. DISCUSSION: An unexpectedly high number of SPs reported symptoms. Fortunately, the symptoms were relatively mild (2.2 on a 5-point scale). Future studies should address the connection between work as an SP and symptoms, and measures should be taken to prevent and treat the symptoms. Debriefing sessions might play a role in this respect.