Issues in enhancing continuing professional development for midwives in clinical practice in Mongolia.

Midwives are professionals who fulfill maternal and child health needs. In Mongolia, midwives were unable to transfer their knowledge and skills to the next generation midwives last few decades. The details of their experiences and the comprehensive aspects of continuing professional development (CPD) are still unclear. This study aimed to assess the current status of midwives in clinical practice through an online symposium. Relevant information was collected from presentations, question-and-answer sessions, and questionnaires. It was found that CPD has unclear training plans, no specialized training, and with them having little experience with CPD. Newly graduated midwives do not have an educational program. As of the current status, midwifery services are not provided at the clinical site in the scope of midwifery job descriptions. This study also discusses the situation of low status and salary in midwifery. Strengthening the system of midwifery CPD like development of the educational program is needed.

International technical cooperation to low- and middle-income countries during the COVID-19 pandemic.

This paper reports on the current status of international technical cooperation, reflecting the views of the Bureau of International Health Cooperation of the National Center for Global Health and Medicine (NCGM) during the COVID-19 pandemic. To appropriately respond to the pandemic, the need for assistance to low- and middle-income countries has increased. Since 2020, there has been a shift from on-site to online international technical cooperation to avoid human contact. While online solutions increased the number of participants in international conferences and training, business travel costs and time were reduced. However, it became necessary to consider not only effective labor-management practices to enable participation in meetings held in different time zones but also quicker ways to develop online training materials, which took a long time. In the future, a hybrid format combining offline and online international technical cooperation will become mainstream.

Lessons learned from the history of postgraduate medical training in Japan: from disease-centred care to patient-centred care in an aging society.

BACKGROUND: Health workers, the core of health service delivery and a key driver of progress towards universal health coverage, must be available in sufficient numbers and distributed fairly to serve the entire population. In addition, the planning and management of the health workforce must be responsive to the changing needs of society, including changes in age structure and epidemiology. Considering these issues, this paper examines in historical perspective the evolution of postgraduate medical training and practice in Japan, from the late nineteenth century to the present. MAIN TEXT: When the first medical schools were established in the country towards the end of the nineteenth century, Japan was a largely agrarian society, with a population of about 30 million and an average life expectancy of 30-40 years. During the twentieth century, life expectancy and the national population continued to increase in a context of rapid economic growth. Since the 1980s, another demographic transition has occurred: low fertility rates and an aging society. As a result, the inputs and skills required from health professionals have changed considerably over time, posing new challenges to the national health sector and the management of human resources for health. CONCLUSIONS: The case of Japan offers valuable lessons for other countries experiencing a rapid epidemiological and demographic transition. To provide medical care that meets health priorities in the communities, we must consider not only the training of specialists, but also ensure the availability of a large cadre of physicians who possess basic skills and can provide patient-centred care. Furthermore, the Japanese experience shows that a highly hierarchical system and organisational culture are ill-suited to respond quickly to the changing demands of society.

Effects of the new fasting standard on sedation in the pediatric emergency room.

BACKGROUND: This study compared adherence to the fasting-time guidelines of the International Committee for the Advancement of Procedural Sedation (ICAPS) and the North American Society of Anesthesiologists (ASA) and complication rates in pediatric patients requiring procedure sedation and analgesia during treatment in the emergency room (ER). METHODS: This retrospective, single-center study was performed between 2016 and 2020, and enrolled patients who received procedural sedation and analgesia in the ER with the fasting times recommended in the ICAPS and ASA guidelines. RESULTS: In total, 857 patients were included. The most frequent indication for procedural sedation and analgesia was fracture reduction in 420 patients (49.0%). Ketamine, the most commonly administered drug, was given to 710 patients (82.8%). Adherence to the ICAPS guidelines was higher (P < 0.01), with 772 (95.7%) and 351 (41.0%) patients, respectively, adhering to the ICAPS and ASA recommendations for food and drink fasting times. Complications occurred in 130 patients (15.2%), including SpO2 <90% in 75 patients (8.7%) and vomiting in 20 patients (2.3%). No serious complications, such as aspiration, cardiac arrest, or death, occurred. The complication rate between the two groups did not differ significantly, with 50 (14.2%) and 127 (15.5%) patients experiencing complications according to the ICAPS and ASA guidelines, respectively (P = 0.586). CONCLUSIONS: The fasting recommendations of the ICAPS guidelines, which propose risk stratification to determine the appropriate fasting time for procedural sedation and analgesia, are more tolerable to patients and the rate of adverse events did not appear to be different from that experienced when following the ASA guidelines.

Creating Clinical Reasoning Assessment Tools in Different Languages: Adaptation of the Pediatric Emergency Medicine Script Concordance Test to Japanese.

Introduction: Clinical reasoning is a crucial skill in the practice of pediatric emergency medicine and a vital element of the various competencies achieved during the clinical training of resident doctors. Pediatric emergency physicians are often required to stabilize patients and make correct diagnoses with limited clinical information, time and resources. The Pediatric Emergency Medicine Script Concordance Test (PEM-SCT) has been developed specifically for assessing physician's reasoning skills in the context of the uncertainties in pediatric emergency practice. In this study, we developed the Japanese version of the PEM-SCT (Jpem-SCT) and confirmed its validity by collecting relevant evidence. Methods: The Jpem-SCT was developed by translating the PEM-SCT into Japanese using the Translation, Review, Adjudication, Pretest, Documentation team translation model, which follows cross-cultural survey guidelines for proper translation and cross-cultural and linguistic equivalences between the English and Japanese version of the survey. First, 15 experienced pediatricians participated in the pre-test session, serving as a reference panel for modifying the test descriptions, incorporating Japanese context, and establishing the basis for the scoring process. Then, a 1-h test containing 60 questions was administered to 75 trainees from three academic institutions. Following data collection, we calculated the item-total correlations of the scores to optimize selection of the best items in the final version of the Jpem-SCT. The reliability of the finalized Jpem-SCT was calculated using Cronbach's α coefficient for ensuring generalizability of the evidence. We also conducted multiple regression analysis of the test score to collect evidence on validity of the extrapolation. Results: The final version of the test, based on item-total correlation data analysis, contained 45 questions. The participant's specialties were as follows: Transitional interns 12.0%, pediatric residents 56.0%, emergency medicine residents 25.3%, and PEM fellows 6.7%. The mean score of the final version of the Jpem-SCT was 68.6 (SD 9.8). The reliability of the optimized test (Cronbach's α) was 0.70. Multiple regression analysis showed that being a transitional intern was a negative predictor of test scores, indicating that clinical experience relates to performance on the Jpem-SCT. Conclusion: This pediatric emergency medicine Script Concordance Test was reliable and valid for assessing the development of clinical reasoning by trainee doctors during residency training.

Predictor of Early Administration of Antibiotics and a Volume Resuscitation for Young Infants with Septic Shock.

(1) Background: It is critical to administer antibiotics and fluid bolus within 1 h of recognizing sepsis in pediatric patients. This study aimed to identify the predictor of the successful completion of a 1-h sepsis bundle for infants with suspected sepsis. (2) Methods: This is an observational study using a prospective registry including febrile young infants (aged < 90 days) who visited a pediatric emergency department with a core body temperature of 38.0 °C or higher and 36.0 °C or lower. Univariate and logistic regression analyses were conducted to determine the predictor (s) of successful sepsis bundle completion. (3) Results: Of the 323 registered patients, 118 patients with suspected sepsis were analyzed, and 38 patients (32.2%) received a bundle-compliant treatment. Among potential variables, such as age, sex, and vital sign parameters, the logistic regression analysis showed that heart rate (odds ratio: OR 1.02; 95% confidence interval: 1.00-1.04) is a significant predictor of the completion of a 1-h sepsis bundle. (4) Conclusions: We found that tachycardia facilitated the sepsis recognition and promoted the successful completion of a 1-h sepsis bundle for young infants with suspected septic shock and a possible indicator for improving the quality of the team-based sepsis management.

Limited Utility of SIRS Criteria for Identifying Serious Infections in Febrile Young Infants.

(1) Background: Young infants have a high risk of serious infection. The Systematic Inflammatory Response Syndrome (SIRS) criteria can be useful to identify both serious bacterial and viral infections. The aims of this study were to evaluate the diagnostic performance of the SIRS criteria for identifying serious infections in febrile young infants and to identify potential clinical predictors of such infections. (2) Methods: We conducted this prospective cohort study including febrile young infants (aged < 90 days) seen at the emergency department with a body temperature of 38.0 °C or higher. We calculated the diagnostic performance parameters and conducted the logistic regression analysis to identify the predictors of serious infection. (3) Results: Of 311 enrolled patients, 36.7% (n = 114) met the SIRS criteria and 28.6% (n = 89) had a serious infection. The sensitivity, specificity, positive predictive value, and positive likelihood ratio of the SIRS criteria for serious infection was 45.9%, 69.4%, 43.5%, 71.4%, 1.5, and 0.8, respectively. Logistic regression showed that male gender, body temperature ≥ 38.5 °C, heart rate ≥ 178 bpm, and age ≤ 50 days were significant predictors. (4) Conclusions: The performance of the SIRS criteria for predicting serious infections among febrile young infants was poor.

The Management of Pediatric Genital Injuries at a Pediatric Emergency Department in Japan.

OBJECTIVES: Genital injuries among children are often associated with consumer products or specific activities. There are few descriptive studies from Asia on pediatric genital injuries seen in the emergency department (ED). The aim of this study was to describe the characteristic features of accidental genital injuries among children. METHODS: A retrospective chart review of children aged 15 years or younger who visited our ED for genital injuries between March 2010 and November 2014 was conducted. Data on age, arrival time at the ED, location of the incident, mechanism of injury, objects, injured organ, consultation with specialists, emergency operation, sedation at the ED, and outcomes were collected and analyzed. RESULTS: One hundred seventy-nine patients were included in this analysis. Girls comprised 71% of the subject pool. The median age was 6 years (interquartile range, 4-9 years). Straddle injuries were the most common form of injury (56%). Male genital injuries occurred mostly outdoors (64%). Common consumer products associated with pediatric genital injuries were furniture (21%), exercise equipment (17%), and bicycles (15%). Thirty-two patients were examined by a surgeon, gynecologist, or urologist. The most commonly injured organs were the penis (55%) in boys and the labia (60%) in girls. Most patients (93%) were treated at the ED and discharged. CONCLUSIONS: The characteristics of accidental genital injuries among Japanese children were similar to those of children in other countries. The strategy for preventing genital injuries used in the West might be applicable to the East Asian context.

Metered-dose inhaler ipratropium bromide for children with acute asthma exacerbation: A prospective, non-randomized, observational study.

BACKGROUND: Ipratropium bromide (IB), when administered with ß2-agonists, is effective in reducing hospital admissions of children presenting to the emergency department (ED) with severe asthma. While IB is commonly delivered in its nebulized form, using a metered-dose inhaler (MDI), can, reportedly, shorten patients' length of stay in the ED. However, the effectiveness and safety of IB administration using an MDI with a spacer have not been established. This study aimed to investigate the effectiveness and safety of MDI-delivered IB in pediatric patients with acute asthma exacerbation. METHODS: This prospective, non-randomized, observational study included patients aged ≥4 years with a history of severe asthma exacerbation. Patients received IB via MDI with a spacer three times at 20-min intervals. IB use was determined by the physicians' treatment policy. Propensity score matching was used to adjust the confounding factors related to IB administration. RESULTS: Of the 158 patients, 88 were treated with IB and 70 were treated without IB. A propensity score-matching analysis extracted 54 patients from each group. We found no statistical difference in the admission rate of the two groups (IB group: 25.9% vs non-IB group: 31.5%; P = 0.67). The post-treatment modified pulmonary index scores (mean ± SD) were also similar (IB: 6.6 ± 2.0 vs non-IB: 6.3 ± 2.5; P = 0.53). Only one patient (1.0%) treated with IB experienced vomiting, which resolved spontaneously. CONCLUSION: The metered-dose inhaler IB was ineffective in reducing the admission rate possibly because it was less effective than a nebulizer for IB inhalation.

The Effect of an Observation Unit on Pediatric Minor Head Injury.

OBJECTIVE: The aim of this study was to evaluate the effect of an observation unit (OU) in an emergency department on reducing unnecessary use of computed tomography (CT) for minor blunt head trauma. METHODS: This study was a retrospective before-and-after study of pediatric patients 18 years or younger with minor blunt head trauma. Patients with a Glasgow Coma Scale score of 14 or 15 who presented to the emergency department were included in the analysis. The rates of head CT use in the period before and after the institution of the OU were compared. RESULTS: In total, 4706 patients were analyzed (2344 from the period before and 2362 from period after OU institution). The median age of the patients was 3 years, and 64% were male in each period. The rates of CT use were 5.7% (95% confidence interval [CI], 4.8%-6.7%) in the period before and 4.0% (95% CI, 3.3%-4.9%) in the period after OU institution (P = 0.01). The relative risk reduction was 0.70 (95% CI, 0.54-0.91). CONCLUSIONS: The rate of CT use decreased by 30% as a result of OU institution. The OU was an effective means of avoiding an unnecessary head CT for pediatric minor head injuries.

Diagnostic Accuracy of a 3-Point Ultrasound Protocol to Detect Esophageal or Endobronchial Mainstem Intubation in a Pediatric Emergency Department.

OBJECTIVES: The aim of this study was to evaluate the diagnostic accuracy of the 3-point approach with ultrasonography for confirming endotracheal tube (ETT) placement in pediatric patients. METHODS: This was a prospective study conducted at a tertiary care center in Japan between March 2014 and March 2016. Children aged 0 to 18 years requiring endotracheal intubation in our emergency department (ED) who underwent ultrasonography for confirming ETT placement were enrolled. Patients who had already undergone a tracheotomy or intubation before arrival at our ED or who had severe neck injuries hindering ultrasonography were excluded. Quantitative capnography and portable chest x-ray imaging were used as the reference standard for the confirmation of proper ETT placement. The main outcome was the diagnostic accuracy of the 3-point approach with ultrasonography for detecting inappropriate ETT placement. RESULTS: In total, 68 patients were enrolled. The median age was 17 months (interquartile range, 8-40), and 51.4% were males. Three (4.4%) and 7 (10.3%) patients had esophageal and endobronchial mainstem intubation, respectively. The patients received emergency intubation due to a dysfunction of the central nervous system (45.6%) or respiratory failure (22.0%). The sensitivity and specificity of esophageal versus tracheal intubation was 100% (95% confidence interval [CI], 54.9%-100.0%) and 100% (95% CI, 97.9%-100.0%), respectively, whereas for endobronchial mainstem intubation versus tracheal intubation, the sensitivity and specificity was 85.7% (95% CI, 56.7%-96.0%) and 98.3% (95% CI, 94.8%-99.5%), respectively. Agreement between the reviewers was high (kappa coefficient, 0.78). CONCLUSION: The 3-point approach with ultrasonography was a feasible method for detecting esophageal and endobronchial mainstem intubation in pediatric patients.

Predicting serious bacterial infection in febrile young infants utilizing body temperature.

BACKGROUND: Febrile young infants have a high risk of serious infection. Although measuring vital sign parameters can serve as a rapid and effective assessment in these patients, their predictive value for serious bacterial infection (SBI) has not been fully investigated. METHODS: This retrospective observational study enrolled febrile (>38.0°C) infants aged <90 days at the time of presentation. Data from the emergency room triage database at Tokyo Metropolitan Children's Medical Center for the period 1 November 2011-30 November 2013, were reviewed. Variables included patient age, gender, and vital sign data, including body temperature, pulse rate, oxygen saturation, definitive diagnosis, and disposition. RESULTS: Two hundred and sixty-nine patients were included, with a mean age of 55 days, and 158 (58.7%) were male. Of the total, 43 patients had an SBI. On logistic regression, body temperature ≥38.5°C (OR, 2.80; 95%CI: 1.37-5.74) was a significant predictor of SBI. CONCLUSION: High-grade fever was found to be a significant predictor of SBI in febrile young infants.

Coronary Lesions and Systemic Inflammatory Response Syndrome in Kawasaki Disease.

INTRODUCTION: In patients with Kawasaki disease (KD), who later develop coronary artery lesions (CALs), several inflammatory cytokines are reportedly higher than in patients without CALs. Systemic inflammatory response syndrome (SIRS) is used as a clinical index of hypercytokinemia. The objective of this study was to determine whether SIRS is related to CAL formation. METHODS: We conducted a retrospective cohort study of KD patients admitted to our hospital between July 2012 and July 2015. The subjects were classified into the SIRS or the non-SIRS group based on their vital signs and blood test results. Their initial treatment was determined by their Kobayashi score. We compared the incidence of CALs between the two groups. RESULTS: Of 357 KD patients, 277 were included in this study and 175 (63.2%) met the SIRS criteria. The incidence of CAL formation at week 1 in the clinical course and at one month after the primary treatment was significantly higher in the SIRS group than in the non-SIRS group (17.7% vs. 7.8%, p = 0.03 and 10.9% vs. 3.9%, p = 0.03, respectively). Multivariate analyses showed that after adjusting for each variable of the Kobayashi score, SIRS was an independent risk factor for CAL formation at week 1 in the clinical course (odds ratio, 2.7; 95% confidence interval, 1.03-7.23; p = 0.04). CONCLUSIONS: SIRS can be a risk factor for CAL in the acute phase of KD.

IPRATROPIUM BROMIDE FOR ACUTE ASTHMA IN CHILDREN: A RETROSPECTIVE TRIAL.

BACKGROUND: Inhaled anticholinergics such as ipratropium bromide (IB), when administered with ß2-agonists, are effective in reducing hospital admissions of children presenting to the emergency department with moderate to severe asthma. However, treatment of acute asthma with IB is still uncommon in Japan. The aim of this study was to investigate the effectiveness and safety of IB for the treatment of pediatric acute asthma. METHODS: We conducted a retrospective study to compare the admission rate of patients who received IB with those who did not. Patients aged 4 years or older with a history of moderate to severe attacks were included. For analysis, propensity score matching was used to adjust the confounding factors related to IB use. Patients received IB by metered-dose inhaler (40µg per dose) with a spacer three times at 20-min intervals. RESULTS: Among 175 patients included in the analysis, 102 patients were treated with IB (IB group) and 73 patients were treated without IB (Non-IB group). A propensity score matching analysis extracted 63 patients from each group. There was no statistical difference between the two groups in terms of admission rate (IB group 12.7% vs Non-IB group 9.5%; p=0.78). One patient (1.0%) treated with IB experienced dryness of the mouth, which resolved spontaneously. CONCLUSIONS: The admission rate did not decline with IB use. Several confounding factors could have influenced and limited our results. A prospective study is needed to investigate the effectiveness of IB in Japan.

Oral injuries in children presenting to a Japanese pediatric emergency room.

BACKGROUND: Oral injuries are common among children, but studies on oral injury according to the presence of foreign objects in the mouth are limited. The aim of this study was to compare injury patterns and their effects in children presenting to a Japanese pediatric emergency room (ER) with and without foreign objects in the mouth. METHODS: Children who were brought to the ER at Tokyo Metropolitan Children's Medical Center with oral injuries between 1 January 2011 and 31 December 2012, were included. Information regarding mechanism of injury, object related to injury, required procedure, and disposition (i.e. placement after ER evaluation: hospitalization or discharge) was collected. Injured subjects with and without foreign objects in the mouth were compared. RESULTS: Three hundred and nineteen subjects were included in analysis. Median age was 26 months. Labial mucosa, tongue, buccal mucosa, and teeth were major locations of injury. Tumble (i.e. fall from standing) was the leading mechanism of injury (50%). Seventy-one subjects (22%) were holding foreign objects in the mouth when injury occurred. A toothbrush was the most common object (31%). Subjects with foreign objects in the mouth were more likely to injure the posterior parts of the mouth, and to require imaging (P = 0.04) and hospital admission (P < 0.001). This was also the case for children with injury due to tumble. CONCLUSIONS: Tumble (i.e. fall from standing) was the most common mechanism of injury. Furthermore, requirement for medical resources increased if children had foreign objects in their mouth. Preventive measures should focus on educating parents about the dangers associated with children moving around while holding objects in the mouth.

An Algorithmic Approach Using Ultrasonography in the Diagnosis of Pediatric Nasal Bone Fracture.

BACKGROUND: Ultrasonography (US) was recently reported as a reliable modality for diagnosing nasal bone fractures. However, whether US is reliable as a screening tool in the pediatric emergency department (ED) remains unknown. This prospective cohort study had a 2-fold aim: to assess the utility of US in the diagnosis of pediatric nasal bone fracture, and to evaluate the validity of our protocol for managing pediatric nasal bone fractures (Fuchu-Kids algorithm). PATIENTS AND METHODS: Among the patients who presented at the ED with facial trauma, those with a suspected nasal bone fracture were enrolled in the study. Patients were treated according to Fuchu-Kids algorithm, and the validity of the protocol using US imaging was evaluated. RESULTS: Among 81 patients who were enrolled during the 1-year study period, 63 patients were able to complete the process described in our protocol for further examination. The diagnostic power of the Fuchu-Kids algorithm had a sensitivity of 91.7%, a specificity of 92.3%, a positive predictive value (PPV) of 88%, and a negative predictive value (NPV) of 94.7%. However, when the performance of US was assessed as a single examination, its sensitivity, specificity, PPV, and NPV were 75%, 92.3%, 85.7%, and 85.7%, respectively. CONCLUSION: Using our algorithm, the majority of patients with nasal bone fracture were successfully diagnosed and screened out successfully. Repeated US imaging is effective when clinical symptoms persist even if the first US imaging was negative for nasal bone fracture. However, a detailed medical interview and clinical examination are mandatory, regardless of the use of US.

Nasopharyngeal foreign body triggered by a blind finger sweep.

A previously healthy 1-year-old boy suddenly began choking and coughing after ingesting a coin. The child's mother attempted to extract the coin by inserting her fingers in his mouth and sweeping the oral cavity. The mother felt the object momentarily with her fingertips but was unable to retrieve it, and brought her son to a local hospital for assistance. The patient was referred to our emergency department (ED) for possible oesophageal obstruction by a foreign body based on the X-ray findings. On arrival at our ED, the child exhibited mild gagging but presented no respiratory symptoms and normal pulmonary examination. The chest X-ray revealed a nasopharyngeal foreign body. The patient was placed under procedural sedation and emergency removal was successfully completed by an otolaryngologist. Subsequently, the patient was discharged without complications.

Epidemiology of Pediatric Convulsive Status Epilepticus With Fever in the Emergency Department: A Cohort Study of 381 Consecutive Cases.

Pediatric convulsive status epilepticus with fever is common in the emergency setting but leads to severe neurological sequelae in some patients. To explore the epidemiology of convulsive status epilepticus with fever, a retrospective cohort covering all convulsive status epilepticus cases with fever seen in the emergency department of a tertiary care children's hospital were consecutively collected. Of the 381 consecutive cases gathered, 81.6% were due to prolonged febrile seizure, 6.6% to encephalopathy/encephalitis, 0.8% to meningitis, and 7.6% to epilepsy. In addition, seizures were significantly longer in encephalopathy/encephalitis cases than in prolonged febrile seizure cases (log rank test, P < .001). These results provide for the first time the pretest probability of final diagnoses in children with convulsive status epilepticus with fever in the emergency setting, and will help optimize the management of pediatric patients presenting to the emergency department with convulsive status epilepticus with fever.