Underprepared: influences of U.S. medical students' self-assessed confidence in immigrant and refugee health care.

BACKGROUND: United States (U.S.) census data from 2017 indicates that the percentage of persons born outside of the U.S. is increasing. However, no studies describe the amount of class time focused on immigrant and refugee health during medical school in the U.S. nor on incoming residents' confidence in providing culturally sensitive care. The objective of this study is to characterize final-year medical students' exposure to immigrant and refugee health and their confidence in caring for these populations. METHODS: A voluntary, cross-sectional survey was sent electronically to fourth-year medical students at twelve U.S. medical schools in 2020, with 707 respondents (46% response rate). Questions addressed respondents' curricular exposure to immigrant and refugee health care during medical school and their confidence in providing culturally sensitive care. Chi-square tests were used to assess relationships between categorical variables, and odds ratios were calculated for dichotomized variables. RESULTS: Most students (70.6%) described insufficient class time dedicated to culturally sensitive care, and many (64.5%) reported insufficient clinical exposure in caring for immigrants/refugees. The odds that incoming residents felt 'usually' or 'always' confident in their ability to provide culturally sensitive care to immigrants and refugees were higher in those with more class time on culturally sensitive care (OR 5.2 [3.6-7.4]), those with more clinical opportunities to care for immigrants and refugees (OR 7.2 [5.1-10.2]), and those who participated in a domestic low-resource or international elective (OR 1.4 [1.02-1.9]). More than half (55.3%) of respondents reported feeling 'not at all' or only 'sometimes' confident in their ability to provide culturally sensitive care to immigrants/refugees. CONCLUSIONS: Most fourth-year U.S. medical students entering residency feel unprepared to deliver culturally sensitive care to immigrants and refugees. This may be mediated by increased exposure to didactic curricula class time and/or experiential clinical activities, as those factors are associated with improved student confidence.

Continuous positive airway pressure for children in resource-limited settings, effect on mortality and adverse events: systematic review and meta-analysis.

OBJECTIVE: Determine non-invasive ventilation with continuous positive airway pressure (CPAP) outcomes for paediatric respiratory distress in low-income and middle-income countries (LMICs). DESIGN: Systematic review and meta-analysis. SETTING: LMIC hospitals. PATIENTS: One month to 15 year olds with respiratory distress. INTERVENTIONS: We searched Medline, Embase, LILACS, Web of Science and Scopus on 7 April 2020. Included studies assessed CPAP safety, efficacy or effectiveness. All study types were included; neonatal only studies were excluded. Data were extracted by two reviewers and bias was assessed. Certainty of evidence was evaluated, and risk ratios (RR) were produced for meta-analyses. (PROSPERO protocol CRD42018084278). RESULTS: 2174 papers were screened, 20 were included in the systematic review and 3 were included in two separate meta-analyses of mortality and adverse events. Studies suitable for meta-analysis were randomised controlled trials (RCTs) from Bangladesh, Ghana and Malawi. For meta-analyses comparing death or adverse events between CPAP and low-flow oxygen recipients, we found no clear CPAP effect on mortality (RR 0.75, 95% CI 0.33 to 1.72) or adverse events (RR 1.52, CI 0.71 to 3.26). We downgraded the certainty of evidence for both death and adverse events outcomes to 'low' due to design issues and results discrepancies across RCTs. CONCLUSIONS: Evidence for CPAP efficacy against mortality and adverse events has low certainty and is context dependent. Hospitals introducing CPAP need to have mechanisms in place to optimise safety in the context it is being used; this includes the location (a high dependency or intensive care area), adequate numbers of staff trained in CPAP use, close monitoring and mechanisms for escalation, daily direct physician supervision, equipment that is age appropriate and user-friendly and continuous monitoring of outcomes and quality of care.

Ophthalmoplegia and cranial nerve deficits in an adolescent with headache.

Tolosa-Hunt syndrome is an idiopathic, inflammatory condition involving the cavernous sinus and is characterized by unilateral, painful ophthalmoparesis. The condition often begins with retro-orbital pain followed by select cranial nerve involvement. We report the case of a 17-year-old female whose presentation with progressive left-sided headache and ophthalmoparesis culminated in the diagnosis of Tolosa-Hunt syndrome. While many of her signs and symptoms have been previously reported in the rare pediatric cases of Tolosa-Hunt syndrome described in the literature, this case illustrates a unique presentation involving cranial nerves V and VII in addition to the more commonly reported cranial nerve III, IV, and VI palsies.

Hemoglobin Sunshine Seth: A Case Report of Low-Oxygen-Affinity Hemoglobinopathy.

Pulse oximetry is routinely used in the newborn nursery for clinical monitoring and to detect critical congenital heart disease. The differential diagnoses for reduced peripheral oxygen saturation in an infant include congenital heart disease, respiratory distress syndrome, transient tachypnea of the newborn, persistent pulmonary hypertension of the newborn, meconium aspiration syndrome, pneumonia, pneumothorax, and sepsis. The diagnostic evaluation for neonatal hypoxemia can be invasive and expensive. When this evaluation is unrevealing, other interventions may be tried without clear benefit to the patient, including, but not limited to, supplemental oxygen. Therefore, it is important to consider alternative, albeit rare, diagnoses, including hemoglobinopathies with abnormal oxygen binding properties. Mutations in the structure of alpha- and beta-globin chains can alter the affinity of hemoglobin for oxygen, and changes in oxygen affinity may result in changes in the oxygen saturation detected by pulse oximetry. These changes may or may not be of clinical significance. This case report describes Hemoglobin Sunshine Seth, a rare low-oxygen-affinity hemoglobin variant presenting as reduced peripheral oxygen saturation in an otherwise well-appearing infant male.

Sertraline-Induced Rhabdomyolysis, Trismus, and Cardiac Arrest in a Child.

Selective serotonin reuptake inhibitors are a commonly used and often effective class of medications in the treatment of mood disorders such as anxiety and depression. Sertraline (1S,4S-N-methyl-4-[3,4-dichlorophenyl]-1,2,3,4-tetrahydro-1-naphthylamine [Zoloft; Pfizer, New York City, NY]) is a frequently used selective serotonin reuptake inhibitor that has shown efficacy in children, adolescents, and adults. We report the case of a 13-year-old boy with sertraline-induced rhabdomyolysis and renal failure, trismus, and cardiopulmonary arrest. Pharmacogenetic testing later revealed our patient had serotonin transporter polymorphisms and enzymatic alterations that put him at risk for increased levels of sertraline and greater likelihood for untoward side effects.