Retention of pediatric resuscitation performance after a simulation-based mastery learning session: a multicenter randomized trial.

OBJECTIVES: Using simulation-based mastery learning, residents can be trained to achieve a predefined performance standard in resuscitation. After mastery is achieved, performance degradation occurs over time. Prior investigations have shown performance retention of 12-14 months following intensive simulation-based mastery learning sessions. We sought to investigate the duration of mastery-level resuscitation performance retention after a single 1- to 2-hour simulation-based mastery learning session. DESIGN: Randomized, prospective trial. SETTING: Medical simulation laboratory. SUBJECTS: Convenience sample of 42 pediatric residents. INTERVENTIONS: Baseline resuscitation performance was determined on four standardized simulation scenarios. After determination of baseline performance, each resident repeated each scenario, as needed, until mastery-level performance was achieved. Residents were then randomized and retested 2, 4, or 6 months later. Statistical analysis on scores at baseline and retesting were used to determine performances changes from baseline and performance retention over time. MEASUREMENTS AND MAIN RESULTS: Forty-two residents participated in the study (12 in 2 mo group, 14 in 4 mo group, and 16 in 6 mo group). At baseline, postgraduate year-3 residents performed better than postgraduate year-1 residents (p = 0.003). Overall performance on each of the four scenarios improved at retesting. The percent of residents maintaining mastery-level performance showed a significant linear decline (p = 0.039), with a drop at each retesting interval; 92% retained mastery at 2 months, 71% at 4 months, and 56% at 6 months. There was no difference in retention between postgraduate year-1, postgraduate year-2, and postgraduate year-3 residents (p = 0.14). CONCLUSIONS: Residents displayed significant improvements in resuscitation performance after a single simulation-based mastery learning session, but performance declined over time, with less than 60% retaining mastery-level performance at 6 months. Our results suggest that relatively frequent refresher training is needed after a single simulation-based mastery learning session. Additional research is needed to determine the duration of performance retention following any specific simulation-based mastery learning intervention.

Facilitating physician reentry to practice: perceived effects of deployments on US army pediatricians' clinical and procedural skills.

INTRODUCTION: US Army pediatricians regularly deploy for 6 to 12 months or longer and many are deployed multiple times during their career. Prolonged breaks in pediatric clinical practice may result in skill degradation, requiring a physician reentry process to prepare pediatricians to return to clinical practice. This study sought to identify which specific pediatric clinical skills were felt to be most affected by deployment. METHODS: Army pediatricians on active duty between January 2012 and March 2012 were surveyed via e-mail to determine their comfort level and experience with clinical encounters and procedural skills prior to and after military deployment. RESULTS: Eighty-three pediatricians were eligible, and 75 responded (90% response rate). Of those received, 65 surveys (78%) were complete and included in the statistical analysis. Over half (54%) of the respondents were deployed longer than 6 months, and 32% were deployed for 12 months or longer. The largest changes in reported comfort were seen in neonatal, pediatric, and adolescent acute care and neonatal routine care, including neonatal and pediatric procedures. There was a significant negative correlation (r = .64; p = .003) between provider's reported exposure to neonatal and pediatric clinical encounters during deployment and provider's comfort with those clinical encounters after deployment. DISCUSSION: US Army pediatricians are required to deploy for extended periods of time and have limited opportunities to practice the full range of their pediatric skills. This break in clinical practice is associated with a significant decline in perceived comfort with both routine and acute pediatric care.

Management of infants born to women infected with hepatitis B in the military healthcare system.

BACKGROUND: Hepatitis B virus (HBV) is endemic worldwide. Given significant rates of infectivity, all infants born to Hepatitis B surface antigen positive mothers need to receive treatment at birth, immunization and post-vaccination serologic testing. However, not all infants complete these requirements. FINDINGS: We performed a retrospective review of the management of infants born to Hepatitis B infected mothers at two large military hospitals in the United States that use a global electronic medical record to track patient results. We then compared these results to those recently published by the National Perinatal Hepatitis B Prevention Program (PHBPP), which does not include hospitals in the United States Military Healthcare System. Our results show that although all infants were managed appropriately at birth and immunization rates were very high, post vaccination follow-up testing rates were much lower than those seen in centers participating in the PHBPP. The rates of post vaccination serological testing were significantly higher for infants born to Hepatitis B e antigen positive mothers and those referred to a pediatric infectious disease specialist. CONCLUSIONS: Despite use of a global electronic medical record in the United States Military Healthcare System, management of HBV-exposed infants does not always follow recommended guidelines. These infants could benefit from a more systematic method of follow-up, similar to the PHBPP, to ensure HBV serologic testing is obtained after the vaccination series is complete.

Human Parechovirus and Other Enteric Viruses in Childcare Attendees in the Era of Rotavirus Vaccines.

OBJECTIVE: We studied the prevalence of enteric viruses, including rotavirus, enterovirus, norovirus, adenovirus, and human parechovirus (HPeV), in stool samples of childcare attendees. The prevalence of enteric viruses was described in children with and those without gastroenteritis. METHODS: Children aged 1-19 months were recruited from 2 childcare centers in Tacoma, Washington, from October 2008 through June 2009. Stool samples were obtained at enrollment and during diarrheal illnesses for enteric virus testing. A symptom diary was completed by parents. RESULTS: One hundred six children (mean age, 10 months) were followed for an average of 170 days. At enrollment, 78 asymptomatic children had stool samples available. Forty-eight illnesses with acute diarrhea (stool samples were available for 24 illnesses) occurred in 37 children. Rotavirus was not detected in samples from symptomatic or asymptomatic children. HPeV was present in 21% and adenovirus in 46% of symptomatic children. At least 1 virus was detected in 78% of samples from asymptomatic children, including HPeV in 27% and adenovirus in 55%. No differences were found in symptom prevalence between HPeV-positive and HPeV-negative diarrheal illnesses. Molecular analysis revealed a diversity of HPeV types. CONCLUSIONS: Our study highlights the high level of HPeV circulation in childcare. The lack of rotavirus detected in this study supports the impact of rotavirus vaccine and emphasizes the need for a greater focus on the epidemiology of non-rotavirus etiologies of gastroenteritis.

Capsular serotype of Staphylococcus aureus in the era of community-acquired MRSA.

Capsular polysaccharide (CP) plays an important role in the pathogenicity and immunogenicity of Staphylococcus aureus, yet the common serotypes of S. aureus isolated from US pediatric patients have not been reported. We investigated capsular serotype as well as methicillin susceptibility, presence of Panton-Valentine leukocidin (PVL), and clonal relatedness of pediatric S. aureus isolates. Clinical isolates were tested for methicillin susceptibility, presence of mecA, lukS-PV and lukF-PV, cap5 and cap8 genes by PCR, and for capsular or surface polysaccharide expression (CP5, CP8, or 336 polysaccharide) by agglutination. Genetic relatedness was determined by pulsed-field gel electrophoresis. All S. aureus isolates encoded cap5 or cap8. Sixty-nine percent of 2004-2005 isolates were methicillin-susceptible (MSSA) and most expressed a detectable capsule. The majority of MRSA isolates (82%) were unencapsulated, exposing an expressed cell wall techoic acid antigen 336. Pulsed-field type USA300 were MRSA, PVL-positive, unencapsulated strains that were associated with deep skin infections and recurrent disease. Over half (58%) of all isolates from invasive pediatric dermatologic infections were USA300. All pediatric isolates contained either capsule type 5 or capsule type 8 genes, and roughly half of the S. aureus clinical disease isolates from our population were diverse MSSA-encapsulated strains. The majority of the remaining pediatric clinical disease isolates were unencapsulated serotype 336 strains of the PVL(+) USA300 community-associated-MRSA clone.

Severe human parechovirus sepsis beyond the neonatal period.

Here we describe a case of viral sepsis beyond the neonatal period caused by human parechovirus subtype 3 (HPeV-3), which manifested as cardio-respiratory failure, hepatitis, and necrotizing enterocolitis (NEC). HPeV-1 and 2 were originally classified as enteroviruses but the advent of sequence analysis led to them being recognized as a new genus in the picornavirus family. Subsequently, nine additional HPeV strains have been reported including HPeV-3 in 1999.(1) The spectrum of disease that these viruses may cause is still unknown, and they are rarely screened for in clinical practice.

Epidemiology of viral respiratory tract infections in a prospective cohort of infants and toddlers attending daycare.

BACKGROUND: The epidemiology of respiratory tract infections (RTIs) in a daycare cohort has not been explored using molecular techniques. OBJECTIVES: (1) Determine the overall incidence of RTIs in a daycare cohort using real-time reverse transcriptase polymerase chain reaction (RT-PCR). (2) Determine the relative incidence and impact of specific respiratory viruses, and characterize and compare clinical features associated with these pathogens. STUDY DESIGN: In this prospective cohort study conducted from February 2006 to April 2008, nasal swabs were obtained from symptomatic children ages 0-30 months enrolled in fulltime daycare. RT-PCR was performed to detect respiratory syncytial virus (RSV), human metapneumovirus (MPV), influenza (Flu) viruses A and B, parainfluenza (PIV), adenovirus (AdV), human coronaviruses (CoV) and rhinovirus (RhV). Symptom diaries were completed for each illness. RESULTS: We followed 119 children (mean age 10 months; range 2-24 months) for 115 child years. The mean annual incidence of RTI per child was 4.2 the first year and 1.2 the second year of the study. At least 1 virus was identified in 67% RTIs. Co-infections were common (27% RTIs), with RhV, CoV, and AdV the most common co-pathogens. PIV was identified in 12% of RTIs with a high incidence of PIV4. The viruses with the greatest impact on our population were RSV, RhV and AdV. CONCLUSIONS: Using molecular techniques, viruses were identified in approximately twice as many RTIs as previously reported in a daycare cohort. Infections with newly identified viruses, such as HMPV and CoV subtypes were less frequent and severe than infections with RSV, AdV and RhV.

Mupirocin resistance related to increasing mupirocin use in clinical isolates of methicillin-resistant Staphylococcus aureus in a pediatric population.

We investigated the proportion of methicillin-resistant Staphylococcus aureus (MRSA) isolates from pediatric patients demonstrating mupirocin resistance related to mupirocin use at our institution. No mupirocin resistance was found in 98% of isolates, whereas mupirocin prescriptions increased by 110%. Resistance rates remained low despite the increasing use of mupirocin.

Small cell ovarian carcinoma: a rare, aggressive tumor masquerading as constipation in a teenager with a fatal outcome.

SUMMARY: A 16-year-old female presented with symptoms consistent with constipation with no constitutional symptoms. Multiple different laxatives were attempted over 4 months and were unsuccessful. This thin female developed an impressively distended, nonacute abdomen within a 2-week period. Histology demonstrated a stage IV small cell carcinoma of the ovary. Her disease initially responded to treatment, but ultimately she relapsed and failed to respond to 2 other chemotherapy combinations, which were based on limited success found in the literature. She ultimately passed away 13 months after the diagnosis, demonstrating the poor prognosis and rapid spread of this rare disease.

Mupirocin resistance screening of methicillin-resistant Staphylococcus aureus isolates at Madigan Army Medical Center.

Mupirocin is an antibiotic used for eradication and infection control of methicillin-resistant Staphylococcus aureus (MRSA). Mupirocin binds to the bacterial isoleucyl tRNA synthetase, thus disrupting bacterial protein synthesis. Four hundred nine MRSA clinical isolates collected in 2006 and 2007 at Madigan Army Medical Center were screened for mupirocin resistance by E test and polymerase chain reaction; 7 MRSA isolates (1.7%) were found to be fully resistant to mupirocin (minimum inhibitory concentration [MIC] by E test: > 1,024 microg/mL), 10 isolates (2.4%) had MIC values of 1 to 32 microg/mL, while 392 MRSA isolates (95.9%) had MIC values of < 1 microg/mL. No trend of increased mupirocin resistance was found when compared with subsequent years. These results show that mupirocin remains a valid infection control measure due to its unique mechanism of action and the high susceptibility rate of MRSA isolates. In addition, rapid screening by polymerase chain reaction of MRSA shows promise in assessing the fully resistant mupirocin phenotype.

Polymicrobial bloodstream infection in pediatric patients: risk factors, microbiology, and antimicrobial management.

BACKGROUND: Few studies focus on polymicrobial bloodstream infections (PBSIs) in children. In previous reports, children with PBSI frequently had complex underlying medical conditions and a high incidence of specific microorganisms, but systematic evaluation with controls was not performed. We postulated that specific clinical risk factors are associated with an increased risk of PBSI, and that illness may be more severe with these infections. Additionally, we suspected that routine empiric antimicrobial therapy may frequently be inadequate to treat the variety of pathogens in PBSI. METHODS: Positive blood cultures from 1998 to 2004 were reviewed. Patients whose cultures grew >1 organism were age-matched with monomicrobial bloodstream infection controls. Records were reviewed to compare their underlying medical conditions, organisms isolated, adequacy of therapy, and clinical characteristics of illness. RESULTS: Twenty-nine episodes of PBSI were identified in 18 subjects. PBSI patients were more likely to have chronic medical conditions, chronic gastrointestinal pathology, central venous catheters, and to be receiving parenteral nutrition than controls. Pathogens found more commonly in PBSI episodes included Enterococcus spp., coagulase-negative staphylococci, and Candida spp. Empiric antimicrobial therapy was less likely to be adequate in patients with PBSI. PBSI patients were hospitalized longer, required longer intensive care and had prolonged bloodstream infection. Subjects with PBSI had prolonged duration of fever and had higher degrees of sepsis than controls. CONCLUSIONS: Chronic medical conditions, particularly gastrointestinal disease, are risk factors for PBSIs. Because clinical illness may be more severe, alteration of the empiric antimicrobial regimen should be considered in some of these patients.

Co-infection of the cotton rat (Sigmodon hispidus) with Staphylococcus aureus and influenza A virus results in synergistic disease.

Bacterial super-infection of influenza patients is the primary cause of excess mortality during influenza pandemics, with Staphylococcus aureus (S. aureus) having the highest fatality rate. The cotton rat (Sigmodon hispidus) is an excellent model for both influenza and S. aureus pathogenesis, and therefore a potential tool to model co-infection. We compared physiologic and pathologic changes in cotton rats infected with both S. aureus and influenza A/Wuhan/359/95 (H3N2), with animals infected with each pathogen alone. Co-infected cotton rats demonstrated significantly higher mortality, lower temperatures on 2 and 3 days post-inoculation (p.i.), higher levels of bacteremia and pulmonary bacterial load 4 days p.i., and worse pathology 7 days p.i. Early indicators of exacerbated disease coincided with higher pulmonary mRNA levels for IL-1beta, IL-6, IL-10 and IFNy, supporting the idea that these may contribute to disease severity. Our results demonstrate that the cotton rat is a good model of influenza and S. aureus co-infection, with increased mortality and hypothermia as well as prolonged bacterial duration indicative of synergistic disease that may be the result of increased induction of both pro- and anti-inflammatory cytokines.

Rotavirus-induced seizures in childhood.

Rotavirus infection is a frequent cause of gastroenteritis in children and accounts for significant morbidity and mortality, especially in the developing world. Less well recognized is the association of rotavirus-induced central nervous system dysfunction, which has been associated with seizure, encephalopathy, and death. Symptoms may vary widely, however, and children can experience short afebrile convulsions as the only manifestation of rotavirus encephalopathy. We report 4 further cases of rotavirus-induced seizures with mild neurologic manifestations. The condition is reviewed and practical management strategies are suggested.

Increasing clindamycin resistance among methicillin-resistant Staphylococcus aureus in 57 northeast United States military treatment facilities.

BACKGROUND: Increasing community-acquired methicillin-resistant Staphylococcus aureus (CA-MRSA) has led many to use clindamycin for CA-MRSA disease, whereas others suggest caution because of inducible clindamycin resistance and rely on drugs such as trimethoprim-sulfamethoxazole (TMP-SMX). AIM: To analyze the change in antibiotic susceptibility pattern of S. aureus isolates from 2001 to 2004 in a closed health care system, a period during which clindamycin and TMP-SMX use increased 99 and 62%, respectively. METHODS: S. aureus cultures from 57 military hospitals and clinics from 2001-2002 and 2003-2004 were compared for body site and antibiotic sensitivity, particularly the potentially inducible clindamycin-susceptible erythromycin-resistant pattern. A portion was evaluated by a double disk diffusion test (D test). RESULTS: Numbers of S. aureus-positive cultures obtained from "wound" sites rose significantly in both pediatric (138 to 215, P < 0.001) and adult (715 to 972, P < 0.001) isolates, with a rise in MRSA in children (6 of 138 to 60 of 215, P < 0.001) and in adults (161 of 715 to 324 of 972, P < 0.001). Clindamycin resistance increased among pediatric S. aureus isolates (1 of 207 to 13 of 327, P < 0.05), whereas >96% remained TMP-SMX-susceptible. Five methicillin-susceptible S. aureus (MSSA), 2 MRSA of 41 pediatric and 36 MSSA, 43 MRSA of 437 adult S. aureus specimens were D test-positive. CONCLUSIONS: In late 2004, most S. aureus from our region are still beta-lactam-susceptible. Most of the MRSA are still susceptible to clindamycin and do not appear to have inducible resistance. We must closely monitor the rates of constitutive and inducible clindamycin resistance as well as consider treatment alternatives that may slow the rate of clindamycin resistance.

Gestational age-specific growth parameters for infants born at US military hospitals.

BACKGROUND: Military hospitals currently use gestational age-specific growth curves based on data collected in Denver, Colo, from 1948 to 1961. A number of population and environmental factors and medical practice changes may make these curves nonrepresentative. OBJECTIVE: Determine if presently used growth curves represent norms for infants born in military hospitals and create new curves for use in military hospitals. METHODS: Data were collected from medical records of tertiary- and primary-care military hospitals. We created growth curves created for birth weight, length, and head circumference and compared these curves at gestational ages 23-42 weeks to previously published norms and to 1998 national vital statistics. Racial and ethnic differences between groups were compared. A retrospective analysis of blood-glucose measurements for healthy term infants was performed to identify potential safety issues. RESULTS: Significant increases in growth parameters were noted for infants born in military hospitals. Specific racial and ethnic groups within the military also had an increase when compared with these groups in the United States as a whole. Less than 1% of infants classified as large for gestational age (LGA) according by old standards but average for gestational age (AGA) according to new curves experienced hypoglycemia. CONCLUSION: Published growth curves may not represent infants born in military hospitals. Term infants born in military hospitals as a group and in racial and ethnic subgroups are larger than term infants born in US civilian hospitals. Prospective use of curves will help to validate their long-term applicability in military and civilian nurseries.