Impact of Chest Radiography on Antibiotic Treatment for Children With Suspected Pneumonia.

OBJECTIVE: National guidelines discourage routine chest radiographs (CXRs) to confirm suspected pneumonia in children managed as outpatients. However, limiting CXRs may lead to antibiotic overuse. We examined the impact of CXRs and clinical suspicion on antibiotic treatment for children with suspected pneumonia. METHODS: Children aged 3 months to 18 years undergoing CXR for suspected pneumonia in a pediatric emergency department were prospectively enrolled. Before CXR, physicians indicated their initial plan for antibiotics (yes or no) and clinical suspicion for radiographic pneumonia (<5%, 5-10%, 11-20%, 21-50%, 51-75%, >75%). Subjects had radiographic pneumonia if their CXRs demonstrated definite or possible findings of pneumonia. We compared antibiotic treatment according to pre-CXR antibiotic plan and suspicion for pneumonia and CXR results. RESULTS: Among the 107 children with a plan for antibiotics before CXR, 72% ultimately received antibiotics compared with 19% of the 1503 children without a pre-CXR plan for antibiotics (P < 0.001). Among those patients with a pre-CXR plan for antibiotics, 96% of children with radiographic pneumonia were ultimately treated compared with 54% without radiographic pneumonia (P < 0.001). If antibiotics were not initially planned, 37% with radiographic pneumonia were treated compared with 8% without radiographic pneumonia (P < 0.001). The use of CXR was more likely to influence antibiotic prescribing patterns when the clinical suspicion of pneumonia was low (<20%). CONCLUSIONS: Among children with high suspicion for pneumonia, CXRs infrequently altered the initial plan for antibiotics. However, when clinical suspicion for pneumonia was low, the use of CXR may reduce unnecessary antibiotic use.

"Getting Started": A Pilot Introductory Narrative Writing Session for Interprofessional Faculty in Academic Health Sciences.

Purpose: We designed and implemented a pilot introductory narrative writing session with the two-fold goal of fostering the dissemination of faculty writing for submission to peer-reviewed journals and other publication venues while simultaneously creating a framework for establishing collaborative and empathic interprofessional teams by enhancing narrative-related competencies. Methods: The session was open to interprofessional faculty at our academic health sciences center. Participants were accepted via a competitive application process, with group size limited to 18 individuals due to the workshop-style format. Learners were reflective of our diverse campus regarding sex, race/ethnicity, department, rank, and professional role. The session began with an experiential seminar providing instruction on writing theory and practice, discussion questions, and reflective writing prompts. The seminar was followed by a writing workshop. We conducted a mixed-methods evaluation to gauge participant satisfaction and educational efficacy. Results: The mixed-methods evaluation revealed that faculty reported high satisfaction with the session as a designated space to contemplate, discuss, practice, share, and critique narrative writing. All learners (18, 100%) rated it "very good" or "excellent" in overall quality and value as well as in relevance to personal growth. Participants reported growth in communication (13, 72%), self-reflection (12, 67%), active listening (12, 67%), writing confidence (11, 61%), perspective-taking (11, 61%), writing skills (10, 56%), and empathy (8, 44%). Discussion: Faculty valued the session as a venue for improving their writing skills and sharing with a diverse group of colleagues about the significance of narrative in relation to their professional lives. Conclusion: Seminar outcomes suggest that narrative-based education for interprofessional health sciences faculty can be effective in achieving the two-fold goal of enhancing writing competencies while simultaneously fostering essential skills for building collaborative and empathic teams to promote high-quality education, research, and whole person clinical care.

Content and outcomes of narrative medicine programmes: a systematic review of the literature through 2019.

OBJECTIVES: Narrative medicine (NM) incorporates stories into health sciences paradigms as fundamental aspects of the human experience. The aim of this systematic review is to answer the research question: how effective is the implementation and evaluation of NM programmes in academic medicine and health sciences? We documented objectives, content and evaluation outcomes of NM programming to provide recommendations for future narrative-based education. METHODS: We conducted a systematic review of literature published through 2019 using five major databases: PubMed, Embase, PsycINFO, ERIC and MedEdPORTAL. Eligible NM programming included textual analysis/close reading of published literature and creative/reflective writing. Qualifying participants comprised individuals from academic medicine and health sciences disciplines. We reviewed and categorised programme goals, content and evaluation activities to assess participant satisfaction and programme efficacy. Two members of the research team assessed the risk of bias, independently screening records via a two-round, iterative process to reach consensus on eligibility. RESULTS: Of 1569 original citations identified, we selected 55 unique programmes (described in 61 records). In all, 41 (75%) programmes reported a form of evaluation; evaluation methods lacked consistency. Twenty-two programmes used quantitative evaluation (13 well described), and 33 programmes used qualitative evaluation (27 well described). Well-described quantitative evaluations relied on 32 different measures (7 validated) and showed evidence of high participant satisfaction and pre-post improvement in competencies such as relationship-building, empathy, confidence/personal accomplishment, pedagogical skills and clinical skills. An average of 88.3% of participants agreed or strongly agreed that the programme had positive outcomes. Qualitative evaluation identified high participant satisfaction and improvement in competencies such as relationship-building, empathy, perspective-taking/reflection, resilience and burnout detection/mitigation, confidence/personal accomplishment, narrative competence, and ethical inquiry. CONCLUSION: Evaluation suggests that NM programming leads to high participant satisfaction and positive outcomes across various competencies. We suggest best practices and innovative future directions for programme implementation and evaluation.

Tularemia.

Tularemia is a rare zoonotic infection caused by the bacterium Francisella tularensis. The disease is endemic in North America and parts of Europe and Asia. Arthropods (ticks and deer flies) are the main transmission vector, and small animals (rabbits, hares, and muskrats) serve as reservoir hosts. The clinical presentation depends on the bacterial subspecies and the route of infection. Recent world events have led to a new recognition of F tularensis as a viable agent of bioterrorism, which has sparked a renewed focus on this pathogen.

Application of the world health organization criteria to predict radiographic pneumonia in a US-based pediatric emergency department.

BACKGROUND: The World Health Organization (WHO) established guidelines that rely on simple clinical signs for the diagnosis of childhood pneumonia in resource-limited settings. Our objective was to evaluate the test characteristics of the WHO criteria for the diagnosis of radiographic pneumonia in the emergency department setting. METHODS: We prospectively collected clinical information from children ≤5 years of age presenting to a US-based pediatric emergency department who had a chest radiograph performed for suspicion of pneumonia. Patients were classified as meeting the WHO case definition of pneumonia if they had both 1) cough or difficulty breathing and 2) age-specific WHO-defined tachypnea. The primary outcome was radiographic pneumonia based on the final radiology report. Among children with cough or with difficulty breathing, receiver operator characteristic curve analysis was used to evaluate the test characteristics of triage respiratory rate, temperature and oxygen saturation for the diagnosis of radiographic pneumonia. RESULTS: Two thousand eight children were enrolled. Median age was 19 months, and 28.5% had tachypnea based upon age-specific respiratory rate thresholds. Of the 324 children with radiographic pneumonia, 111 met the WHO case definition of pneumonia (sensitivity = 34.3%, 95% confidence interval: 29.1-39.7). Triage respiratory rate demonstrated an area under the curve of 0.54 for the diagnosis of radiographic pneumonia. The area under the curve for triage temperature and oxygen saturation was 0.56 and 0.60, respectively. CONCLUSIONS: The WHO criteria demonstrated poor sensitivity for the diagnosis of radiographic pneumonia in a US-based pediatric emergency department. Compared with respiratory rate, oxygen saturation offered slightly improved test characteristics. Although applied to a different target population, these findings suggest the WHO criteria may not be a sensitive screening tool for the diagnosis of pneumonia in children.