Hofmeister effects influence bulk nanostructure in a protic ionic liquid.

HYPOTHESIS: The origins and behaviour of specific ion effects have been studied in water for more than a century, and more recently in nonaqueous molecular solvents. However, the impacts of specific ion effects on more complex solvents such as nanostructured ionic liquids remains unclear. Here, we hypothesise that the influence of dissolved ions on the hydrogen bonding in the nanostructured ionic liquid propylammonium nitrate (PAN) constitutes a specific ion effect. EXPERIMENTS: We performed molecular dynamics simulations of bulk PAN and 1-50 mol% PAN-PAX (X = halide anions F-, Cl-, Br-, I-) and PAN-YNO3 (Y = alkali metal cations, Li+, Na+, K+ and Rb+) solutions to investigate how monovalent salts influence the bulk nanostructure in PAN. FINDINGS: The key structural characteristic in PAN is a well-defined hydrogen bond network formed within the polar and non-polar domains in its nanostructure. We show that dissolved alkali metal cations and halide anions have significant and unique influences on the strength of this network. Cations (Li+, Na+, K+ and Rb+) consistently promote hydrogen bonding in the PAN polar domain. Conversely, the influence of halide anions (F-, Cl-, Br-, I-) is ion specific; while F- disrupts PAN hydrogen bonding, I- promotes it. The manipulation of PAN hydrogen bonding therefore constitutes a specific ion effect - i.e. a physicochemical phenomena caused by the presence of dissolved ions, which are dependent on these ions' identity. We analyse these results using a recently proposed predictor of specific ion effects developed for molecular solvents, and show that it is also capable of rationalising specific ion effects in the more complex solvent environment of an ionic liquid.

Patient and public involvement in paediatric medical education.

The benefits of involving patients and the public in medical education are well documented, however there is a need to further explore how this can be translated to the setting of paediatric medical education. This article aims to identify how organisations can facilitate the involvement of paediatric patients and their parents/carers.While involving children in research can present challenges, we describe examples where organisations have successfully involved young people in clinical research and selection of research topics.Involving paediatric patients and their parents/carers in medical education helps develop a patient centred approach to practice for medical students. Participation of paediatric patients in objective structured clinical examination (OSCE) examinations is employed by many medical schools, however allowing them the ability to provide a 'global score' may have the potential to assess skills such as communication and empathy in addition to medical knowledge.The Royal College of Paediatrics and Child Health (RCPCH) have provided a framework on how to involve children in health services, addressing practical considerations such as funding and facilities. This framework could be applied by organisations seeking to actively involve children in paediatric medical education. Potential barriers and facilitators are explored in this article.During the COVID-19 pandemic, involving young people and their families in medical student teaching became challenging. We describe virtual bedside teaching sessions which actively involved paediatric patients and their families, which showed that many patients and parents prefer virtual consultations.Involving paediatric patients and their families in medical education is strongly advocated by the General Medical Council (GMC) and RCPCH. Organisations should actively seek out opportunities to become involved in the development of medical education resources as we describe in this paper.

Addressing recruitment and retention in paediatrics: a pipeline to a brighter future.

BACKGROUND: In the UK, the number of junior doctors completing foundation programme, and the number of trainees applying to paediatrics has been in decline in recent years. The NHS is at 'breaking point', exacerbated by workforce shortages, chronic underfunding, increasing service demand and poor job satisfaction within healthcare workers. Issues in recruitment and retention of paediatricians 'threaten the safety of our children's health', according to the Royal College of Paediatrics and Child Health. AIM: To explore what strategies have been described in the literature to enhance recruitment and retention in paediatrics. METHODS: A scoping review methodology was conducted, employing a qualitative approach to review the literature. The studies included were English-language studies. 16 full-text articles were reviewed and analysed. STUDY FINDINGS: There is a paucity of data in the literature that describes evidence-based approaches to enhancing retention and recruitment in paediatrics. The most important strategies employed to help are identified and grouped into six main themes. These include professional advocacy, workforce diversity, mentorship, improving working conditions, career flexibility and enhancing educational opportunities. The authors have created a 'paediatric pipeline' paradigm of 'identify, engage, recruit, retain and champion', which allow us to present these themes in a pragmatic way for paediatricians and policymakers. CONCLUSIONS: While some issues share similarities with other specialties in difficulty, much of the context and potential remedies within paediatrics are distinct. A strategic, multi-agency collaborative approach is required urgently to address the significant issues that face both paediatrics and the healthcare system.

ACTup: advanced communication training simulation enhanced by actors trained in the Stanislavski system.

Strong communication, empathy and interpersonal skills are crucial to good clinical practice. Actors trained in interpretations of the Stanislavski system draw on their own life experience to develop the character. We hypothesised that simulation enhanced by trained actors would be an ideal way for our senior trainees to develop advanced communication skills. We developed a communication training course based on challenging situations which occur in paediatrics like child death and safeguarding. Actors were briefed and invited to develop characters that would behave and respond as a parent/carer might do in complex and stressful clinical scenario. Paediatric trainees then participated in simulations, with a focus on communication skills. Feedback and debrief were provided by a multidisciplinary faculty. The impact of the course was evaluated by analysis of data collected in focus groups held after the simulation. Trainees noted the actor's ability to respond in vivo to emotive situations and felt it was much more effective than their previous experience of simulation with simulated patients without formal training. Actors were able to offer feedback on aspects of body language, tone and use of language from a non-medical perspective. Actors enhanced the realism of the simulations by changing their language and emotional performance in response to the trainee's performance, improving trainee engagement.

Cough and you'll miss it.

A 9-month-old boy presented to the emergency department with acute wheeze. He had a background of cleft lip repair at 4 months and was awaiting palatoplasty. He had mild eczema but had never had a previous wheezy episode, and was awaiting cardiology follow-up for a small patent ductus arteriosus (PDA). He had been at the child minder when symptoms began abruptly with no witnessed event. On assessment, the wheeze had resolved, saturations were 98% breathing air, respiratory rate was 34 breaths per minute and he was afebrile. He was discharged home with safety net advice.He represented 2 days later with cough, wheeze and shortness of breath. On examination, he had subcostal recession and there was reduced air entry on the right. There was no wheeze, crepitations or obvious organomegaly. Oxygen saturations were 98% breathing air, respiratory rate was 38 breaths per minute and he was afebrile. Oral amoxicillin was given.

Fifteen-minute consultation: A practical approach to remote consultations for paediatric patients during the COVID-19 pandemic.

OBJECTIVE: This practical approach to the use of telehealth aims to offer clinicians a framework for video and telephone interactions with children and families accessing healthcare. DESIGN: Using a standardised case to illustrate how video and telephone consultations can be used during the COVID-19 pandemic. SETTING: The emergence of 2019 novel coronavirus (COVID-19) is having a massive impact on society. Routine face-to-face consultations were reduced to reduce potential spread of the virus. Clinicians still need to provide ongoing safe care, particularly for more complex patients. Telehealth is the delivery of healthcare services across geographical barriers using information and communication technologies to improve health outcomes. INTERVENTION: In this article, we describe a 'How to' approach to using virtual consultations based on our experience and a review of expert guidelines. CONCLUSION: Virtual consultations can be more convenient and have the potential to improve access for patients. Many have embraced these technologies for the first time during this pandemic.

Fifteen-minute consultation: Severe traumatic brain injury in paediatrics.

Paediatric traumatic brain injury (TBI) is a non-degenerative, acquired brain insult. Following a blow or penetrating trauma to the head, normal brain function is disrupted. If it occurs during the early stages of development, deficits may not immediately become apparent but unfold and evolve over time. We address the difficulties that arise when treating a child with severe TBI.

Familiarity with the clinical environment, achieved by priming, improves time to antibiotic administration in a simulated paediatric sepsis scenario: a randomised control trial.

AIM: The early administration of antibiotics in sepsis reduces mortality and improves outcomes. This randomised control trial evaluated the effect of environmental priming (EP) on healthcare student performance in a simulated paediatric sepsis scenario. METHODS: Medical and nursing students were randomised into primed and unprimed groups. Primed groups received both direct and virtual priming. Each group completed a standardised simulated sepsis scenario. Time to achieve five key clinical interventions was recorded. Mini focus groups were conducted to explore perceptions of EP. RESULTS: There were 26 primed and 26 unprimed groups. The primed students were quicker to complete all five interventions and statistically significantly quicker to achieving intravenous (IV) access (median 350 s vs 373 s, p=0.02), administering IV antibiotics (median 648 s vs 760 s, p=0.045) and seeking senior help (median 703 s vs 780 s, p=0.02). Primed students did not feel that they had gained any specific advantage from being primed. CONCLUSIONS: EP can improve clinical performance. Implications for practice include incorporating EP of key clinical areas into local induction, standardisation of resuscitation areas and regular use of in situ simulation.

Intubation drug pack containing pre-filled syringes reduces the time to endotracheal intubation in a simulated paediatric emergency.

To determine if an intubation drugs pack containing pre-filled syringes can reduce the time to endotracheal intubation compared with standard care during a simulated paediatric emergency. Twenty doctors (10 consultants and 10 registrars) who worked in the paediatric intensive care unit or anaesthetic department of a tertiary paediatric hospital were asked to participate in an in situ simulated emergency paediatric intubation scenario. The participants were instructed to prepare and administer intubation medications. They were randomised to either an intubation drug pack, containing pre-filled syringes or to standard care where each of the drugs had to be individually drawn-up. The mean time to intubation when using the pre-filled syringes of 159.5 s was over three times faster than with standard care of 497.5 s (p<0.001), allowing intubation to occur on average 5 min and 38 s earlier. Utilising an intubation drug pack containing pre-filled syringes significantly reduced the time from decision to intubate to intubation in a simulated paediatric emergency. This applied irrespective of clinical experience with registrars utilising the pre-filled syringes outperforming consultant anaesthetists when they used standard care.

How to use perianal examination in children.

No examination of a child's abdomen or gastrointestinal system is complete without an examination of the 'backside' or perineum, however there is often reluctance among paediatricians to perform this examination routinely. This article aims to describe how to use perineal examination in infants and children. It discusses the indications and stepwise approach to performing a per-rectal examination and interpretation of the findings one could expect to encounter. We include four cases encompassing the major conditions, both congenital and acquired, that paediatricians should be aware of and how they were managed in our institution.

Ssssh for Handover: protected medical handover; optimising quality and prioritising safety-a regional initiative.

Medical handover is one of the most commonly performed actions in the healthcare system today. While it is performed regularly, it is often not done as effectively as it could or should be. 1 Many organisations have implemented systems and structures to improve the quality and impact of their handover process. These include advocating senior presence, introducing validated handover tools and an emphasis on multidisciplinary involvement. 2 A protected handover prioritises safety, enhances communication and encourages improvement in handover effectiveness. Our local pilot and subsequent regional initiative has begun actively addressing this issue using a low-cost, interprofessional, multispeciality quality improvement initiative.

How to use the videofluoroscopy swallow study in paediatric practice.

In paediatric practice feeding, eating, drinking and swallowing difficulties are present in up to 1% of children. Dysphagia is any disruption to the swallow sequence that results in compromise to the safety, efficiency or adequacy of nutritional intake. Swallowing difficulties may lead to pharyngeal aspiration, respiratory compromise or poor nutritional intake. It causes sensory and motor dysfunction impacting on a child's ability to experience normal feeding. Incoordination can result in oral pharyngeal aspiration where fluid or food is misdirected and enters the airway, or choking where food physically blocks the airway The incidence is much higher in some clinical populations, including children with neuromuscular disease, traumatic brain injury and airway malformations. The prevalence of dysphagia and aspiration-related disease is increasing secondary to the better survival of children with highly complex medical and surgical needs. This article aims to outline the indications for performing videofluoroscopy swallow (VFS). This includes the technical aspects of the study, how to interrupt a VFS report and some of the limitations to the study.