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.

How to interpret spirometry in a child with suspected asthma.

Asthma is one of the most common chronic disorders of childhood. The typical symptoms are a result of reversible airway obstruction. There is no 'gold-standard' test to diagnose asthma, but the most commonly used investigation to help with a diagnosis is spirometry. This article outlines some of the technical aspects of spirometry together with how the forced expiration manoeuver and bronchodilator responsiveness testing can be performed and interpreted in a child with suspected asthma.

Comparison of medical student performance in summative undergraduate paediatric examinations and a clinician-designed minimum accepted competency (MAC) assessment.

BACKGROUND: It is recognised that newly qualified doctors feel unprepared in many areas of their daily practice and that there is a gap between what students learn during medical school and their clinical responsibilities early in their postgraduate career. This study aimed to assess if undergraduate students and junior paediatric doctors met a Minimum Accepted Competency (MAC) of knowledge. METHODS: The knowledge of undergraduates and junior paediatric doctors was quantitatively assessed by their performance on a 30-item examination (the MAC examination). The items within this examination were designed by non-academic consultants to test 'must-know' knowledge for starting work in paediatrics. The performance of the students was compared with their official university examination results and with the performance of the junior doctors. RESULTS: For the undergraduate student cohort (n = 366) the mean examination score achieved was 45.9%. For the junior doctor cohort (n = 58) the mean examination score achieved was significantly higher, 64.2% (p < 0.01). 68% of undergraduate students attained the pass mark for the MAC examination whilst a significantly higher proportion, 97%, passed their official university examination (p < 0.01). A Spearman's rank co-efficient showed a moderate but statistically significant positive correlation between students results in their official university examinations and their score in the MAC examination. CONCLUSION: This work demonstrates a disparity between both student and junior doctor levels of knowledge with consultant expectations from an examination based on what front-line paediatricians determined as "must-know" standards. This study demonstrates the importance of involvement of end-users and future supervisors in undergraduate teaching.

Calibration of confidence and assessed clinical skills competence in undergraduate paediatric OSCE scenarios: a mixed methods study.

BACKGROUND: The relationship between confidence and competence in clinical skills development is complex but important. This study aims to determine undergraduate paediatric student confidence in performing three common paediatric clinical skills framed as Objective Structured Clinical Examination (OSCE) scenarios and to compare this with subsequent assessed performance. The study also aims to explore possible barriers to successful paediatric skills completion. METHODS: A mixed-methods study was conducted on medical students. Cross-sectional questionnaire data relating to confidence in performing a number of paediatric skills were compared with assessed paediatric skills competency. Focus groups were carried out to identify themes in paediatric skills completion to triangulate this data. RESULTS: Eighty-five medical students participated in the study. Students had high levels of pre-test confidence in their ability to perform paediatrics skills. However agreement between pre-test confidence and subsequent task performance was poor and students had significantly greater belief in their skills ability than was subsequently demonstrated. Focus groups identified paediatric skills complexity, conflicting teaching and having limited supervised skills opportunities and as being possible contributory factors to this discrepancy. CONCLUSIONS: Student paediatric skills confidence is not matched by performance. The reasons for this are diverse but mostly modifiable. A major factor is the lack of supervised skills experience with appropriate feedback to support students in learning to calibrate their confidence against their competence. A number of recommendations are made including the introduction of formative assessment opportunities.

The use of remote video directly observed therapy to improve both inhaler technique and adherence to asthma medications.

Incorrect inhaler technique and non-adherence to inhaled preventer therapy often is the cause of poorly controlled asthma. Detecting and correcting non-adherence in asthma therapy has proven difficult. In addition, while patients may be able to demonstrate correct inhaler technique at the clinic recent evidence suggests that critical errors in inhaler technique occur in the home setting. Remote video directly observed therapy (vDOT) has recently been described as a potentially useful tool for addressing non-adherence while also allowing timely correction of inhaler technique errors. In this mini-review we describe the use of vDOT in asthma management.

How we teach children with asthma to use their inhaler: a scoping review.

BACKGROUND: One reason that asthma remains poorly controlled in children is poor inhaler technique. Guidelines recommend checking inhaler technique at each clinical visit. However, they do not specify how best to train children to mastery of correct inhaler technique. Many children are simply shown how to use inhalers which results in less than 50% with correct inhaler technique. The aim of this scoping review is to explore published literature on teaching methods used to train children to master correct inhaler technique. METHODS: We searched (from inception onwards): Medline, Embase, Scopus, Web of Science, CINAHL and the Cochrane library. We included quantitative studies, (e.g. randomised controlled trials, cohort studies and case-control studies), published from 1956 to present, on teaching inhaler technique to children with asthma. Data was extracted onto a data charting table to create a descriptive summary of the results. Data was then synthesised with descriptive statistics and visual mapping. RESULTS: Thirty-three papers were identified for full text analysis. Educational interventions were found to be taking place in a variety of clinical areas and by a range of healthcare professional disciplines. 'Brief-Instruction' and 'Teach-Back' were identified as two primary methods of providing inhaler technique training in the majority of papers. Secondary themes identified were; use of written instruction, physical demonstration, video demonstrations and/or use of inhaler devices to augment inhaler technique training. CONCLUSION: There are a variety of means by which inhaler technique has been taught to children. These methods are likely applicable to all inhaler types and often involve some form of physical demonstration. Children of all ages can be trained to use their inhaler correctly and by a range of healthcare professionals. We have not analysed the effectiveness of these different interventions, but have described what has been trialled before in an attempt to focus our attentions on what may potentially work best. The majority of these methods can be dichotomised to either 'Brief-Intervention' or 'Teach-Back'. Based on our analysis of this scoping review, we consider the following as areas for future research; how many times does a given intervention have to be done in order to have the desired effect? For what duration does the intervention need to continue to have a long-lasting effect? And, what is the best outcome measure for inhaler technique?. TRIAL REGISTRATION: Systematic review registration: Open Science Framework (osf.io/n7kcw).

Implementation of a Children's Safe Asthma Discharge Care Pathway Reduces the Risk of Future Asthma Attacks in Children-A Retrospective Quality Improvement Report.

Background: Many children attend Emergency Departments (ED) and Out of Hours (OoH) frequently for acute asthma. Follow up care is often suboptimal leaving these children at risk of a future attacks. We report on the development, implementation and evaluation of a safe asthma discharge care pathway (SADCP). Methods: This is a retrospective report on the development, implementation and evaluation of outcomes of a SADCP. The pathway was based on the Teach-to-goal educational methodology that supported the mastery correct inhaler technique and ability to action the personalized asthma action plan (PAAP). Children with frequent asthma attacks were entered as they were discharged from the Emergency Department or ward. The first training session occurred within 1-3 weeks of the index asthma attack with 2 further sessions in the following 8 weeks. Children exiting the pathway were discharged either back to primary care or to a hospital clinic. Results: 81 children entered the pathway (median age 5 years) with 72 discharged from the ED and 9 from the medical wards of the Royal Belfast Hospital for Sick Children. At pathway entry 13% had correct inhaler technique, 10% had a Personalized Asthma Action Plan (PAAP), and 5% had >80% (45% >50%) repeat refill evidence of adherence to inhaled corticosteroid over the previous 12 months. On pathway exit all children demonstrated correct inhaler technique and were able to action their PAAP. One year later 51% and 95% had refill evidence of >80% and >50% adherence. Comparisons of the 12 months before and 12 months after exit from the pathway the median number of emergency ED or OoH asthma attendances and courses of oral corticosteroids reduced to zero with >75% having no attacks requiring this level of attention. Similar findings resulted when the SADCP was implemented in a district general hospital pediatric unit. Conclusion: Implementing an asthma care pathway, using Teach-to-Goal skill training methods and frequent early reviews after an index asthma attack can reduce the future risk of asthma attacks in the next 6 to 12 months.

Differential cytopathogenesis of respiratory syncytial virus prototypic and clinical isolates in primary pediatric bronchial epithelial cells.

BACKGROUND: Human respiratory syncytial virus (RSV) causes severe respiratory disease in infants. Airway epithelial cells are the principle targets of RSV infection. However, the mechanisms by which it causes disease are poorly understood. Most RSV pathogenesis data are derived using laboratory-adapted prototypic strains. We hypothesized that such strains may be poorly representative of recent clinical isolates in terms of virus/host interactions in primary human bronchial epithelial cells (PBECs). METHODS: To address this hypothesis, we isolated three RSV strains from infants hospitalized with bronchiolitis and compared them with the prototypic RSV A2 in terms of cytopathology, virus growth kinetics and chemokine secretion in infected PBEC monolayers. RESULTS: RSV A2 rapidly obliterated the PBECs, whereas the clinical isolates caused much less cytopathology. Concomitantly, RSV A2 also grew faster and to higher titers in PBECs. Furthermore, dramatically increased secretion of IP-10 and RANTES was evident following A2 infection compared with the clinical isolates. CONCLUSIONS: The prototypic RSV strain A2 is poorly representative of recent clinical isolates in terms of cytopathogenicity, viral growth kinetics and pro-inflammatory responses induced following infection of PBEC monolayers. Thus, the choice of RSV strain may have important implications for future RSV pathogenesis studies.

Use of oximetry to screen for paediatric obstructive sleep apnoea: is one night enough and is 6 hours too much?

INTRODUCTION: Nocturnal pulse oximetry can be used to screen for obstructive sleep apnoea (OSA) using the McGill Oximetry Score (MOS). The MOS has a time threshold for a technically adequate study of 6 hours. It has been suggested that one night of oximetry is sufficient to screen for OSA using the MOS. AIMS: (1) To evaluate night-to-night variation of the MOS. (2) To determine the impact of recording three nights of oximetry on the screening yield for OSA. (3) To explore whether useful MOS data are discarded when a threshold of 6 hours of oximetry recording is used. METHODS: A retrospective study of nocturnal pulse oximetry done at home over three consecutive nights in paediatric patients with suspected OSA. Studies were scored (MOS) using thresholds of ≥6 and ≥4 hours of recording. RESULTS: A total of 329 patients were studied. MOS scores over three nights showed only fair to moderate agreement. On the first night 126 patients (38%) screened positive for OSA. When three nights of oximetry were done 195 patients (59%) screened positive on at least one of the nights. There were 48 patients with studies of between 4 and 6 hours duration on one or more nights. If these studies are scored 20 patients (42%) would screen positive for OSA on at least one night based on scoring these studies alone. CONCLUSION: One night of oximetry screening may not be sufficient to screen for OSA. Lowering the time threshold to ≥4 hours may increase the screening capability of nocturnal oximetry.

A 3-D well-differentiated model of pediatric bronchial epithelium demonstrates unstimulated morphological differences between asthmatic and nonasthmatic cells.

There is a need for reproducible and effective models of pediatric bronchial epithelium to study disease states such as asthma. We aimed to develop, characterize, and differentiate an effective, an efficient, and a reliable three-dimensional model of pediatric bronchial epithelium to test the hypothesis that children with asthma differ in their epithelial morphologic phenotype when compared with nonasthmatic children. Primary cell cultures from both asthmatic and nonasthmatic children were grown and differentiated at the air-liquid interface for 28 d. Tight junction formation, MUC5AC secretion, IL-8, IL-6, prostaglandin E2 production, and the percentage of goblet and ciliated cells in culture were assessed. Well-differentiated, multilayered, columnar epithelium containing both ciliated and goblet cells from asthmatic and nonasthmatic subjects were generated. All cultures demonstrated tight junction formation at the apical surface and exhibited mucus production and secretion. Asthmatic and nonasthmatic cultures secreted similar quantities of IL-8, IL-6, and prostaglandin E2. Cultures developed from asthmatic children contained considerably more goblet cells and fewer ciliated cells compared with those from nonasthmatic children. A well-differentiated model of pediatric epithelium has been developed that will be useful for more in vivo like study of the mechanisms at play during asthma.

Exposure and attitudes to adolescent health amongst Paediatric trainees in Northern Ireland: a mixed-methods study.

AIMS: To determine the exposure and attitudes of paediatric trainees towards adolescent medicine. METHODS: All paediatric trainees in the Northern Ireland deanery (n=107) were invited to participate in an online survey in March 2016. The questionnaire was based on the 'Modified Perceptions of Adolescent Issues and Resources: Care of Adolescents' questionnaire. The questions included a 5-point Likert scale (1-strongly disagree, 5-strongly agree) as well as open questions. All paediatric trainees were invited to attend focus groups to expand on themes generated from the questionnaire. RESULTS: The response rate for the paediatric survey was 62% (n=66). Trainees identified adolescence as an area of importance similar to paediatrics and neonates; however, knowledge, confidence, skills and previous teaching in adolescent medicine were lower than for neonatal medicine and general paediatrics. Trainees who saw ≥6 adolescent patients per week were more likely to rate the importance of adolescent medicine higher. Trainees' perceived confidence, knowledge, self-rated skills and prior teaching in adolescent medicine were strongly correlated. Most (70%) respondents stated that they had not attended an adolescent transition clinic during their postgraduate training. Undergraduate and postgraduate teaching for adolescent health was rated poorly. CONCLUSIONS: This project identified a paediatric trainee population that are aware of the importance of adolescent health but with low perceived knowledge, skills and confidence to manage them. Education is required to enhance learning and improve outcomes for adolescent patients.

How we teach children with asthma to use their inhaler: a scoping review protocol.

BACKGROUND: One reason that asthma remains poorly controlled in children is poor inhaler technique. Current guidelines recommend checking inhaler technique at each clinical visit. However, they do not specify how best to train children to mastery of correct inhaler technique. Currently, many children are simply shown how to use inhalers (brief intervention) which results in less than 50% with correct inhaler technique. The aim of this scoping review is to explore published literature on teaching methods used to train children to master correct inhaler technique. METHODS: This scoping review will follow the Arksey and O'Malley framework and the Joanna Briggs Institute guidelines. We will search (from inception onwards) MEDLINE, Embase, Scopus, Web of Science, CINAHL and the Cochrane library. We will include quantitative studies (e.g. randomised controlled trials, cohort studies and case-control studies), published from the year 1956 to present, on teaching the skill of inhaler technique to children with asthma. Two reviewers will complete all screening and data abstraction independently. Data will be extracted onto a data charting table to create a descriptive summary of the results. Data will then be synthesised with descriptive statistics and visual mapping. DISCUSSION: This scoping review will provide a broad overview of currently used educational methods to improve inhaler technique in children with asthma. The analysis will allow us to refine future research in this area by focusing on the most effective methods and optimising them. SYSTEMATIC REVIEW REGISTRATION: Open Science Framework ( osf.io/n7kcw ).

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.

Night-to-night variation of pulse oximetry in children with sleep-disordered breathing.

BACKGROUND: Sleep-disordered breathing is a common and serious feature of many paediatric conditions and is particularly a problem in children with Down syndrome. Overnight pulse oximetry is recommended as an initial screening test, but it is unclear how overnight oximetry results should be interpreted and how many nights should be recorded. METHODS: This retrospective observational study evaluated night-to-night variation using statistical measures of repeatability for 214 children referred to a paediatric respiratory clinic, who required overnight oximetry measurements. This included 30 children with Down syndrome. We measured length of adequate trace, basal SpO2, number of desaturations (>4% SpO2 drop for >10 s) per hour ('adjusted index') and time with SpO2<90%. We classified oximetry traces into normal or abnormal based on physiology. RESULTS: 132 out of 214 (62%) children had three technically adequate nights' oximetry, including 13 out of 30 (43%) children with Down syndrome. Intraclass correlation coefficient for adjusted index was 0.54 (95% CI 0.20 to 0.81) among children with Down syndrome and 0.88 (95% CI 0.84 to 0.91) for children with other diagnoses. Negative predictor value of a negative first night predicting two subsequent negative nights was 0.2 in children with Down syndrome and 0.55 in children with other diagnoses. CONCLUSIONS: There is substantial night-to-night variation in overnight oximetry readings among children in all clinical groups undergoing overnight oximetry. This is a more pronounced problem in children with Down syndrome. Increasing the number of attempted nights' recording from one to three provides useful additional clinical information.