Teaching pediatric otoscopy skills to the medical student in the clinical setting: preceptor perspectives and practice.

BACKGROUND: Acute otitis media (AOM) is the most frequent indication for antibiotic treatment of children in the United States. Its diagnosis relies on visualization of the tympanic membrane, a clinical skill acquired through a deliberate approach. Instruction in pediatric otoscopy begins in medical school. Medical students receive their primary experience with pediatric otoscopy during the required pediatric clerkship, traditionally relying on an immersion, apprentice-type learning model. A better understanding of their preceptors' clinical and teaching practices could lead to improved skill acquisition. This study investigates how pediatric preceptors (PP) and members of the Council on Medical Student Education in Pediatrics (COMSEP) perceive teaching otoscopy. METHODS: A 30-item online survey was administered to a purposeful sample of PP at six institutions in 2017. A comparable 23-item survey was administered to members through the 2018 COMSEP Annual Survey. Only COMSEP members who identified themselves as teaching otoscopy to medical students were asked to complete the otoscopy-related questions on the survey. RESULTS: Survey respondents included 58% of PP (180/310) and 44% (152/348) of COMSEP members. Forty-one percent (62/152) of COMSEP member respondents identified themselves as teaching otoscopy and completed the otoscopy-related questions. The majority agreed that standardized curricula are needed (PP 78%, COMSEP members 97%) and that all graduating medical students should be able to perform pediatric otoscopy (PP 95%, COMSEP members 79%). Most respondents reported usefulness of the American Academy of Pediatrics (AAP) AOM guidelines (PP 95%, COMSEP members 100%). More COMSEP members than PP adhered to the AAP's diagnostic criteria (pediatric preceptors 42%, COMSEP members 93%). The most common barriers to teaching otoscopy were a lack of assistive technology (PP 77%, COMSEP members 56%), presence of cerumen (PP 58%, COMSEP members 60%), time to teach in direct patient care (PP 46%, COMSEP members 48%), and parent anxiety (PP 62%, COMSEP members 54%). CONCLUSIONS: Our study identified systemic and individual practice patterns and barriers to teaching pediatric otoscopy. These results can inform education leaders in supporting and enabling preceptors in their clinical teaching. This approach can be adapted to ensure graduating medical students obtain intended core clinical skills.

Population Pharmacokinetics and Safety of Solithromycin following Intravenous and Oral Administration in Infants, Children, and Adolescents.

Solithromycin is a novel fluoroketolide antibiotic which was under investigation for the treatment of community-acquired bacterial pneumonia (CABP). A phase 1 study was performed to characterize the pharmacokinetics (PK) and safety of solithromycin in children. Eighty-four subjects (median age, 6 years [age range, 4 days to 17 years]) were administered intravenous (i.v.) or oral (capsules or suspension) solithromycin (i.v., 6 to 8 mg/kg of body weight; capsules/suspension, 14 to 16 mg/kg on days 1 and 7 to 15 mg/kg on days 2 to 5). PK samples were collected after the first and multidose administration. Data from 83 subjects (662 samples) were combined with previously collected adolescent PK data (n = 13; median age, 16 years [age range, 12 to 17 years]) following capsule administration to perform a population PK analysis. A 2-compartment PK model characterized the data well, and postmenstrual age was the only significant covariate after accounting for body size differences. Dosing simulations suggested that 8 mg/kg i.v. daily and oral dosing of 20 mg/kg on day 1 (800-mg adult maximum) followed by 10 mg/kg on days 2 to 5 (400-mg adult maximum) would achieve a pediatric solithromycin exposure consistent with the exposures observed in adults. Seventy-six treatment-emergent adverse events (TEAEs) were reported in 40 subjects. Diarrhea (6 subjects) and infusion site pain or phlebitis (3 subjects) were the most frequently reported adverse events related to treatment. Two subjects experienced TEAEs of increased hepatic enzymes that were deemed not to be related to the study treatment. (The phase 1 pediatric studies discussed in this paper have been registered at ClinicalTrials.gov under identifiers NCT01966055 and NCT02268279.).

Clostridium difficile stool shedding in infants hospitalized in two neonatal intensive care units is lower than previous point prevalence estimates using molecular diagnostic methods.

BACKGROUND: The point prevalence of Clostridium difficile stool shedding in hospitalized infants from two neonatal intensive care units (NICUs) was examined utilizing standard clinical testing compared with duplex PCR to identify toxigenic and non-toxigenic C. difficile strains. METHODS: All infants from the two NICUs affiliated with a single academic medical center were eligible for inclusion. Stool collection was blinded to patient characteristics and occurred during a one week period at each NICU and repeated with a second weeklong collection 6 months later to increase sample size. Stools were tested for C. difficile using EIA (GDH/toxin A/B) with samples testing +/+ or +/- subsequently evaluated by Loop-Mediated Isothermal Amplification (LAMP) and by duplex PCR amplification of tcdB and tpi (housekeeping) genes. Cytotoxicity assays were performed on all samples positive for C. difficile by any modality. RESULTS: Eighty-four stools were collected from unique infants for evaluation. EIA results showed 6+/+ [7.1%], 7 +/- [8.3%], and 71 -/- [84.5%] samples. All 6 EIA +/+ were confirmed as toxigenic C. difficile by LAMP; 6/7 EIA +/- were negative by LAMP with one identified as invalid. Duplex PCR concurred with LAMP in all 6 stools positive for toxigenic C. difficile. PCR identified 2 EIA -/- stools positive for tpi, indicating shedding of non-toxigenic C. difficile. Cytotoxicity assay was positive in 4/6 duplex PCR positive samples and negative for all stools that were EIA +/- but negative by molecular testing. CONCLUSIONS: C. difficile blinded point prevalence in infants from two NICUs was 7.1% by molecular methods; and lower than expected based on historical incidence estimates. In house duplex PCR had excellent concordance with clinically available LAMP and EIA tests, and added detection of non-toxigenic C. difficile strain shedding. Evolving NICU care practices may be influencing the composition of infant gut microbiota and reducing the point prevalence of C. difficile shedding in NICU patient stools.

A Novel Public Library-Based Sexually Transmitted Infection Screening Program for Younger High-Risk Groups in Omaha, Nebraska, USA.

Chlamydia trachomatis (CT) and Neisseria gonorrhoeae (NG) are the two most commonly reported sexually transmitted infections (STIs) in the United States (U.S.) and Douglas County, Nebraska has STI rates consistently above the U.S. average. The Douglas County Health Department (DCHD) developed an outreach CT and NG screening program in public libraries to address the problem beyond the traditional STI clinic setting. This study evaluates the effectiveness of the program and identifies factors predictive of CT and NG infections. A retrospective review of surveys of library patrons and DCHD traditional STI clinic clients who submitted urine tests for CT and NG from June 2010 through April 2014 was done. Chi square, Fisher exact, Student's t tests, univariate and multivariate logistic regression were conducted. A total of 977 library records and 4871 DCHD clinic records were reviewed. The percent positive was lower in the library than in the traditional clinic for CT (9.9 vs. 11.2 %) and NG (2.74 vs. 5.3 %) (p = 0.039 and p < 0.001, respectively). Library clients were more likely to be 19 years and younger (OR 6.14, 95 % CI: 5.0, 7.5), Black (OR 3.4, 95 % CI: 2.8, 4.1), and asymptomatic (OR 12.4, 95 % CI: 9.9, 15.5) compared to traditional clinic clients. The library STI screening program effectively reaches a younger, asymptomatic, and predominantly Black population compared to a traditional health department clinic site.

Early-onset neonatal sepsis.

Early-onset sepsis remains a common and serious problem for neonates, especially preterm infants. Group B streptococcus (GBS) is the most common etiologic agent, while Escherichia coli is the most common cause of mortality. Current efforts toward maternal intrapartum antimicrobial prophylaxis have significantly reduced the rates of GBS disease but have been associated with increased rates of Gram-negative infections, especially among very-low-birth-weight infants. The diagnosis of neonatal sepsis is based on a combination of clinical presentation; the use of nonspecific markers, including C-reactive protein and procalcitonin (where available); blood cultures; and the use of molecular methods, including PCR. Cytokines, including interleukin 6 (IL-6), interleukin 8 (IL-8), gamma interferon (IFN-γ), and tumor necrosis factor alpha (TNF-α), and cell surface antigens, including soluble intercellular adhesion molecule (sICAM) and CD64, are also being increasingly examined for use as nonspecific screening measures for neonatal sepsis. Viruses, in particular enteroviruses, parechoviruses, and herpes simplex virus (HSV), should be considered in the differential diagnosis. Empirical treatment should be based on local patterns of antimicrobial resistance but typically consists of the use of ampicillin and gentamicin, or ampicillin and cefotaxime if meningitis is suspected, until the etiologic agent has been identified. Current research is focused primarily on development of vaccines against GBS.

Rapid HIV Screening in an Urban Jail: How Testing at Exit With Linkage to Community Care Can Address Perceived Barriers.

Despite recommendations from the CDC, only 36 % of jails offer routine HIV screening to inmates. Our purpose was to explore the feasibility of rapid HIV testing at release from an urban jail, and to identify potential barriers to this process. This project was incorporated into an established partnership between the jail, local academic medical center, and local public health department. We offered rapid HIV testing at the time of release to 507 jail inmates over a 7 week period of 2013. Three hundred and two (60 %) inmates elected testing. All participating inmates received individual test counseling, HIV prevention education, and linkage to care in the community prior to release. All tested inmates received results before release; one inmate screened positive for HIV and was linked to care. Previous HIV testing was the most frequently cited reason given (60 %) among the 205 inmates who declined at the time of the study. Utilizing the partnership between the jail, public health, and an academic medical center, we found that rapid HIV testing at exit was feasible and acceptable in this urban jail setting and could provide immediate linkage to care for those in need.

Infection Prevention and Control Implications of Special Pathogens in Children.

Special pathogens are broadly defined as highly transmissible organisms capable of causing severe disease in humans. Children's hospital healthcare personnel (HCP) should be prepared to identify patients possibly infected with a special pathogen, isolate the patient to minimize transmission, and inform key infection prevention, clinical, and public health stakeholders. Effective preparedness requires resources and practice with attention to education, policies and procedures, drills and training, and supplies. Successfully preparing for special pathogens is an important measure toward keeping communities, HCP, and patients and families safe in this global age that brings pathogens from across the world to our doorstep.

Ten ways to make the most of World Antimicrobial Awareness Week.

One fundamental strategy to address the public health threat of antimicrobial resistance (AMR) is improved awareness among the public, prescribers, and policy makers with the aim of engaging these groups to act. World Antimicrobial Awareness Week is an opportunity for concerted and consistent communication regarding practical strategies to prevent and mitigate AMR. We highlight 10 ways for antimicrobial stewards to make the most of World Antimicrobial Awareness Week.

Embracing Diversity and Inclusion in Psychiatry Leadership.

Recognizing and embracing culture, diversity, and inclusion is essential to the practice of high-quality clinical care in medicine and, more specifically, in psychiatry. When leadership lacks diversity, the organizational policies and norms may skew toward devaluing the importance of diversity and inclusion. Considering the significant underrepresentation at the academic faculty level, substantive individual and systemic efforts are required to recruit, retain, and advance a diverse and inclusive student pipeline and faculty in academic psychiatry. For meaningful progress to be made, leaders in psychiatry must resemble an increasingly diverse field of psychiatry residents who serve a more diverse community of patients.

Powassan encephalitis and Colorado tick fever.

This article discusses two tick-borne illnesses: Powassan encephalitis, a rare cause of central nervous system infection caused by the Powassan virus, and Colorado tick fever, an acute febrile illness caused by the Colorado tick fever virus common to the Rocky Mountain region of North America.

Costs Associated with Ebola Preparedness at a Freestanding Pediatric Assessment Center.

The 2014-2016 West Africa Ebola outbreak led US hospitals to prepare to treat Ebola patients, with significant attributable costs. A nationwide preparedness transition to a tiered approach allowed regional allocation of preparedness resources for Ebola frontline, assessment, and treatment hospitals. Preparedness costs for assessment centers were significant and largely uncompensated. Infect Control Hosp Epidemiol 2017;38:1367-1369.

Assessment of initial serum vancomycin trough concentrations and their association with initial empirical weight-based vancomycin dosing and development of nephrotoxicity in children: a multicenter retrospective study.

STUDY OBJECTIVES: To determine whether a relationship exists between initial serum vancomycin trough concentrations and initial empirical vancomycin dose, patient weight, and patient age, and to determine the risks for vancomycin-associated nephrotoxicity in pediatric patients stratified by hospital setting. DESIGN: Stepwise linear and multinomial logistic regression analysis of retrospectively collected data. SETTING: Two geographically distinct children's tertiary care medical centers. PATIENTS: A total of 316 pediatric patients without preexisting renal dysfunction who were managed outside of the neonatal intensive care unit and were treated with at least 3 doses of vancomycin for gram-positive bacterial infections and had at least one serum vancomycin trough concentration between January 1, 2008, and July 31, 2010. MEASUREMENTS AND MAIN RESULTS: Elevated vancomycin trough concentrations had no statistically significant relationship with initial empirical vancomycin dosing across all hospital settings. Serum vancomycin trough concentrations (lower than 15 mg/L or 15-20 mg/L) were not associated with increased risk of nephrotoxicity. Concomitant nephrotoxic agents, however, including loop diuretics, vasopressors, angiotensin-converting enzyme (ACE) inhibitors, and nonsteroidal antiinflammatory drugs (NSAIDs) were significantly associated with the development of nephrotoxicity in medical-surgical and intensive care patients. Based on this analysis, use of loop diuretics and vasopressors increased the odds of developing nephrotoxicity (odds ratio [OR] 42.8 [p=0.001] and 18.4 [p=0.02], respectively). Use of NSAIDS and ACE inhibitors also increased the odds of developing nephrotoxicity (OR 18.6 [p=0.02] and 4.7 [p=0.03], respectively). CONCLUSION: No significant associations were found between initial empirical weight-based vancomycin dosing or elevated serum trough concentrations and development of nephrotoxicity in children; rather, nephrotoxicity was associated with combination therapy with vancomycin and other potentially nephrotoxic agents.

Comparison of Opt-In Versus Opt-Out Testing for Sexually Transmitted Infections Among Inmates in a County Jail.

A majority of jails in the United States rely on an opt-in (voluntary) rather than opt-out (universal) approach to testing for sexually transmitted infections (STIs). This study compares an opt-out approach at intake to opt-in testing during incarceration and estimates the prevalence of common STIs among jail inmates. Data derive from a universal intake pilot testing program (n = 298) and an established, student-led voluntary testing program (n = 1,963), respectively. The adjusted prevalence as well as the odds of testing positive for chlamydia were significantly higher in the opt-out program (p = .025 and .008, respectively) than the opt-in program but not for gonorrhea (p = .402 and .300, respectively). These results demonstrate the potential public health benefit of implementation of universal STI testing of jail inmates.

Neonatal late-onset sepsis following peripherally inserted central catheter removal: association with antibiotic use and adverse line events.

The objective of the study was to evaluate incidence of and risk factors for sepsis following peripherally inserted central catheter (PICC) removal. The retrospective cohort study looked at neonatal intensive care unit patients with PICC placement between February 2003 and June 2010 at a single medical center in the United States. Results showed that 14/216 patients (6.5%) had sepsis within 5 days of PICC removal. PICC removal because of adverse events was significantly associated with sepsis (P = .017). Antibiotic use before PICC removal did not have a significant impact on sepsis. The conclusions of the study are that removal of PICCs because of adverse events is significantly associated with late-onset neonatal sepsis and that antibiotic use at the time of PICC removal is not associated with a decline in sepsis rate.

Antigenemia, RNAemia, and innate immunity in children with acute rotavirus diarrhea.

Antigenemia is commonly detected in children with acute rotavirus diarrhea, but the prevalence of viremia has not been clearly defined. We examined antigenemia in plasma and RNAemia in peripheral blood mononuclear cells (PBMC) of children with acute diarrhea by EIA, RT-PCR, and Southern hybridization, using primers and a probe specific to rotavirus NSP4 gene. We detected the presence of rotavirus antigen in 33.3% and almost full-length NSP4 gene in 70.8% of the acute-phase plasma and PBMC, respectively. In contrast, antigenemia and RNAemia were detected in 0% and 4.2% of the convalescent-phase plasma and PBMC, respectively, which were similar to antigenemia (0%) and RNAemia (7.7%) in healthy controls. We demonstrated an increase in the proportions of activated myeloid dendritic cells (mDC) and activated plasmacytoid DC (pDC) in acute-phase PBMC of patients when compared to those in convalescent phase of patients and in PBMC of healthy controls. The activation of mDC peaked on days 2-4 after illness onset, and the activation of acute-phase pDC appeared to correlate with levels of antigenemia. High prevalence of NSP4 gene in acute-phase PBMC indicates possible rotavirus replication in white blood cells, and extraintestinal spread and the activation of DC may have implications for the prevention of rotavirus disease in children.