Antimicrobial resistance in Enterobacterales infections among children in sub-Saharan Africa: a systematic review and meta-analysis.

Background: The burden of antimicrobial resistance (AMR) has been estimated to be the highest in sub-Saharan Africa (SSA). The current study estimated the proportion of drug-resistant Enterobacterales causing infections in SSA children. Methods: We searched MEDLINE/PubMed, Embase and the Cochrane Library to identify retrospective and prospective studies published from 01/01/2005 to 01/06/2022 reporting AMR of Enterobacterales causing infections in sub-Saharan children (0-18 years old). Studies were excluded if they had unclear documentation of antimicrobial susceptibility testing methods or fewer than ten observations per bacteria. Data extraction and quality appraisal were conducted by two authors independently. The primary outcome was the proportion of Enterobacterales resistant to antibiotics commonly used in paediatrics. Proportions were combined across studies using mixed-effects logistic regression models per bacteria and per antibiotic. Between-study heterogeneity was assessed using the I2 statistic. The protocol was registered with PROSPERO (CRD42021260157). Findings: After screening 1111 records, 122 relevant studies were included, providing data on more than 30,000 blood, urine and stool isolates. Escherichia coli and Klebsiella spp. were the predominant species, both presenting high proportions of resistance to third-generation cephalosporins, especially in blood cultures: 40.6% (95% CI: 27.7%-55%; I2: 85.7%, number of isolates (n): 1032) and 84.9% (72.8%-92.2%; I2: 94.1%, n: 2067), respectively. High proportions of resistance to other commonly used antibiotics were also observed. E. coli had high proportions of resistance, especially for ampicillin (92.5%; 95% CI: 76.4%-97.9%; I2: 89.8%, n: 888) and gentamicin (42.7%; 95% CI: 30%-56.5%; I2: 71.9%, n: 968). Gentamicin-resistant Klebsiella spp. were also frequently reported (77.6%; 95% CI: 65.5%-86.3%; I2: 91.6%, n: 1886). Interpretation: High proportions of resistance to antibiotics commonly used for empirical treatment of infectious syndromes were found for Enterobacterales in sub-Saharan children. There is a critical need to better identify local patterns of AMR to inform and update clinical guidelines for better treatment outcomes. Funding: No funding was received.

Carriage of third-generation cephalosporin-resistant and carbapenem-resistant Enterobacterales among children in sub-Saharan Africa: a systematic review and meta-analysis.

Background: The increasing resistance of Enterobacterales to third-generation cephalosporins and carbapenems in sub-Saharan Africa (SSA) is a major public health concern. We did a systematic review and meta-analysis of studies to estimate the carriage prevalence of Enterobacterales not susceptible to third-generation cephalosporins or carbapenems among paediatric populations in SSA. Methods: We performed a systematic literature review and meta-analysis of cross-sectional and cohort studies to estimate the prevalence of childhood (0-18 years old) carriage of extended-spectrum cephalosporin-resistant Enterobacterales (ESCR-E) or carbapenem-resistant Enterobacterales (CRE) in SSA. Medline, EMBASE and the Cochrane Library were searched for studies published from 1 January 2005 to 1 June 2022. Studies with <10 occurrences per bacteria, case reports, and meta-analyses were excluded. Quality and risk of bias were assessed using the Newcastle-Ottawa scale. Meta-analyses of prevalences and odds ratios were calculated using generalised linear mixed-effects models. Heterogeneity was assessed using I2 statistics. The protocol is available on PROSPERO (CRD42021260157). Findings: Of 1111 studies examined, 40 met our inclusion criteria, reporting on the carriage prevalence of Enterobacterales in 9408 children. The pooled carriage prevalence of ESCR-E was 32.2% (95% CI: 25.2%-40.2%). Between-study heterogeneity was high (I2 = 96%). The main sources of bias pertained to participant selection and the heterogeneity of the microbiological specimens. Carriage proportions were higher among sick children than healthy ones (35.7% vs 16.9%). The pooled proportion of nosocomial acquisition was 53.8% (95% CI: 32.1%-74.1%) among the 922 children without ESCR-E carriage at hospital admission. The pooled odds ratio of ESCR-E carriage after antibiotic treatment within the previous 3 months was 3.20 (95% CI: 2.10-4.88). The proportion of pooled carbapenem-resistant for Enterobacterales was 3.6% (95% CI: 0.7%-16.4%). Interpretation: This study suggests that ESCR-E carriage among children in SSA is frequent. Microbiology capacity and infection control must be scaled-up to reduce the spread of those multidrug-resistant microorganisms. Funding: There was no funding source for this study.

Formative assessments during COVID-19 pandemic: an observational study on performance and experiences of medical students.

Background: Because of COVID-19, the 2020 written medical examinations were replaced by mandatory formative online assessments. This study aimed to determine students' performance, self-assessment of performance, and perception about the switch from a summative to a formative approach. Methods: Medical students from year 2 to 5 (n=648) were included. They could repeat each test once or twice. They rated their performance after each attempt and were then given their score. Detailed feedback was given at the end of the session. An online survey determined medical students' perception about the reorganization of education. Two items concerned the switch from summative to formative assessments Results: Formative assessments involved 2385 examinees totaling 3197 attempts. Among examinees, 30.8% made at least 2 attempts. Scores increased significantly at the second attempt (median 9.4, IQR 10.8), and duration decreased (median -31.0, IQR 48.0). More than half of examinees (54.6%) underestimated their score, female students more often than male. Low performers overestimated, while high performers underestimated their scores. Students approved of the switch to formative assessments. Stress was lessened but motivation for learning decreased. Conclusions: Medical students' better scores at a second attempt support a benefit of detailed feedback, learning time and re-test opportunity on performance. Decreased learning motivation and a minority of students repeating the formative assessments point to the positive influence of summative assessment on learning.

Host biomarkers and combinatorial scores for the detection of serious and invasive bacterial infection in pediatric patients with fever without source.

BACKGROUND: Improved tools are required to detect bacterial infection in children with fever without source (FWS), especially when younger than 3 years old. The aim of the present study was to investigate the diagnostic accuracy of a host signature combining for the first time two viral-induced biomarkers, tumor necrosis factor-related apoptosis-inducing ligand (TRAIL) and interferon γ-induced protein-10 (IP-10), with a bacterial-induced one, C-reactive protein (CRP), to reliably predict bacterial infection in children with fever without source (FWS) and to compare its performance to routine individual biomarkers (CRP, procalcitonin (PCT), white blood cell and absolute neutrophil counts, TRAIL, and IP-10) and to the Labscore. METHODS: This was a prospective diagnostic accuracy study conducted in a single tertiary center in children aged less than 3 years old presenting with FWS. Reference standard etiology (bacterial or viral) was assigned by a panel of three independent experts. Diagnostic accuracy (AUC, sensitivity, specificity) of host individual biomarkers and combinatorial scores was evaluated in comparison to reference standard outcomes (expert panel adjudication and microbiological diagnosis). RESULTS: 241 patients were included. 68 of them (28%) were diagnosed with a bacterial infection and 5 (2%) with invasive bacterial infection (IBI). Labscore, ImmunoXpert, and CRP attained the highest AUC values for the detection of bacterial infection, respectively 0.854 (0.804-0.905), 0.827 (0.764-0.890), and 0.807 (0.744-0.869). Labscore and ImmunoXpert outperformed the other single biomarkers with higher sensitivity and/or specificity and showed comparable performance to one another although slightly reduced sensitivity in children < 90 days of age. CONCLUSION: Labscore and ImmunoXpert demonstrate high diagnostic accuracy for safely discriminating bacterial infection in children with FWS aged under and over 90 days, supporting their adoption in the assessment of febrile patients.

Factors associated with nonadherence to the American Academy of Pediatrics 2014 bronchiolitis guidelines: A retrospective study.

The latest guideline from the American Academy of Pediatrics for the management of bronchiolitis has helped reduce unnecessary interventions and costs. However, data on patients still receiving interventions are missing. In patients with acute bronchiolitis whose management was assessed and compared with current achievable benchmarks of care, we aimed to identify factors associated with nonadherence to guideline recommendations. In this single-centre retrospective study the management of bronchiolitis pre-guideline (Period 1: 2010 to 2012) was compared with two periods post-guideline (Period 2: 2015 to 2016, early post-guideline; and Period 3: 2017 to 2018, late post-guideline) in otherwise healthy infants aged less than 1 year presenting at the Children's University Hospitals of Geneva (Switzerland). Post-guideline, bronchodilators were more frequently administered to older (>6 months; OR 25.8, 95%CI 12.6-52.6), and atopic (OR 3.5, 95%CI 1.5-7.5) children with wheezing (OR 5.4, 95%CI 3.3-8.7). Oral corticosteroids were prescribed more frequently to older (>6 months; OR 5.2, 95%CI 1.4-18.7) infants with wheezing (OR 4.9, 95% CI 1.3-17.8). Antibiotics and chest X-ray were more frequently prescribed to children admitted to the intensive care unit (antibiotics: OR 4.2, 95%CI 1.3-13.5; chest X-ray: OR 19.4, 95%CI 7.4-50.6). Latest prescription rates were all below the achievable benchmarks of care. In summary, following the latest American Academy of Pediatrics guideline, older, atopic children with wheezing and infants admitted to the intensive care unit were more likely to receive nonevidence-based interventions during an episode of bronchiolitis. These patient profiles are generally excluded from bronchiolitis trials, and therefore not specifically covered by the current guideline. Further research should focus on the benefit of bronchiolitis interventions in these particular populations.

Viremia as a predictor of absence of serious bacterial infection in children with fever without source.

Most children with fever without source (FWS) require diagnostic laboratory tests to exclude a serious bacterial infection (SBI), often followed by admission and empirical antibiotics. As febrile children with a viral infection are less likely to have a SBI, identifying patients with systemic viral infection could contribute to exclude SBI. We evaluated whether the presence of virus in the blood could be used as a biomarker to rule out SBI. Children < 3 years old with FWS were prospectively enrolled and had real-time (reverse-transcription) PCR performed on the blood for adenovirus, enterovirus, parechovirus, and HHV6. 20/135 patients had SBI, and in 47/135, at least one virus was detected in the blood. Viremia had a higher sensitivity and negative predictive value (90% and 96%) to rule out SBI compared to CRP (65% and 93%) and PCT (55% and 90%). The odds ratio (OR) for the presence of SBI among non-viremic patients was 5.8 (p = 0.0225), compared to 5.5 for CRP ≥ 40 mg/l (p = 0.0009) and 3.7 for PCT ≥ 0.5 ng/mL (0.0093). This remained significant after adjusting for CRP and PCT (OR 5.6 and 5.9, respectively; p = 0.03 for both). Area under the ROC curve for CRP and PCT were 0.754 and 0.779, respectively, but increased to 0.803 and 0.832, respectively, when combined with viremia. CONCLUSION: The presence of viremia had a better performance than commonly used biomarkers to rule-out SBI and could potentially be used in conjunction with CRP and/or PCT in the evaluation of children with FWS. Larger studies should evaluate the role of point-of-care testing of viruses by (revere-transcription) PCR in the plasma in management algorithms of children with FWS. WHAT IS KNOWN: • Most children with FWS have a viral infection, but up to 15% have a SBI; most require laboratory tests, and many admission and empirical antibiotics. • Children with a viral infection are less likely to have a SBI. WHAT IS NEW: • Children with a systemic viral infection are less likely to have an SBI. • Viremia is a better predictor of absence of SBI than commonly used biomarkers and could potentially be used in conjunction with CRP and/or PCT in the evaluation of children with FWS.

Medical students' perceptions and coping strategies during the first wave of the COVID-19 pandemic: studies, clinical implication, and professional identity.

BACKGROUND: The unfolding of the COVID-19 pandemic during spring 2020 has disrupted medical education worldwide. The University of Geneva decided to shift on-site classwork to online learning; many exams were transformed from summative to formative evaluations and most clinical activities were suspended. We aimed to investigate the perceived impact of those adaptations by the students at the Faculty of Medicine. METHODS: We sent an online self-administered survey to medical students from years 2 to 6 of the University of Geneva, three months after the beginning of the pandemic. The survey explored students' main activities during the first three months of the pandemic, the impact of the crisis on their personal life, on their training and on their professional identity, the level of stress they experienced and which coping strategies they developed. The survey consisted of open-ended and closed questions and was administered in French. RESULTS: A total of 58.8% of students responded (n = 467) and were homogeneously distributed across gender. At the time of the survey, two thirds of the participants were involved in COVID-19-related activities; 72.5% voluntarily participated, mainly fueled by a desire to help and feel useful. Many participants (58.8%) reported a feeling of isolation encountered since the start of the pandemic. Main coping strategies reported were physical activity and increased telecommunications with their loved ones. Most students described a negative impact of the imposed restrictions on their training, reporting decreased motivation and concentration in an unusual or distraction-prone study environment at home and missing interactions with peers and teachers. Students recruited to help at the hospital in the context of increasing staff needs reported a positive impact due to the enriched clinical exposure. Perceived stress levels were manageable across the surveyed population. If changed, the crisis had a largely positive impact on students' professional identity; most highlighted the importance of the health care profession for society and confirmed their career choice. CONCLUSION: Through this comprehensive picture, our study describes the perceived impact of the pandemic on University of Geneva medical students, their training and their professional identity three months after the start of the pandemic. These results allowed us to gain valuable insight that reinforced the relevance of assessing the evolution of the situation in the long run and the importance of developing institutional support tools for medical students throughout their studies.

Diagnostic Accuracy of SARS-CoV-2 Rapid Antigen Detection Testing in Symptomatic and Asymptomatic Children in the Clinical Setting.

Antigen-based rapid diagnostic tests (RDTs) are used in children despite the lack of data. We evaluated the diagnostic performance of the Panbio-COVID-19 Ag Rapid Test Device (P-RDT) in children. Symptomatic and asymptomatic participants 0 to 16 years old had two nasopharyngeal swabs (NPS) for both reverse transcription-PCR (RT-PCR) and P-RDT. A total of 822 participants completed the study, of which 533 (64.9%) were symptomatic. Among the 119 (14.5%) RT-PCR-positive patients, the P-RDT sensitivity was 0.66 (95% confidence interval [CI] 0.57 to 0.74). Mean viral load (VL) was higher among P-RDT-positive patients than negative ones (P < 0.001). Sensitivity was 0.91 in specimens with VL of >1.0E6 IU/ml (95% CI 0.83 to 0.99) and decreased to 0.75 (95% CI 0.66 to 0.83) for specimens >1.0E3 IU/ml. Among symptomatic participants, the P-RDT displayed a sensitivity of 0.73 (95% CI 0.64 to 0.82), which peaked at 1.00 at 2 days post-onset of symptoms (DPOS) (95% CI 1.00 to 1.00), then decreased to 0.56 (95% CI 0.23 to 0.88) at 5 DPOS. There was a trend toward lower P-RDT sensitivity in symptomatic children <12 years (0.62 [95% CI 0.45 to 0.78]) versus ≥12 years (0.80 [95% CI 0.69 to 0.91]; P = 0.09). In asymptomatic participants, the P-RDT displayed a sensitivity of 0.43 (95% CI 0.26 to 0.61). Specificity was 1.00 in symptomatic and asymptomatic children (95% CI 0.99 to 1.00). The overall 73% and 43% sensitivities of P-RDT in symptomatic and asymptomatic children, respectively, was below the 80% cutoff recommended by the World Health Organization. We observed a correlation between VL and P-RDT sensitivity, as well as variation of sensitivity according to DPOS, a major determinant of VL. These data highlight the limitations of RDTs in children, with the potential exception in early symptomatic children ≥12yrs.

Pneumococcal vaccine implementation in the African meningitis belt countries: the emerging need for alternative strategies.

Introduction: Besides meningococcal disease, the African meningitis belt (AMB) region is also affected by pneumococcal disease. Most AMB countries have introduced pneumococcal conjugate vaccines (PCV) following a schedule of three primary doses without a booster or a catch-up campaign. PCV is expected to help control pneumococcal disease through both direct and indirect effects. Whether and how fast this will be achieved greatly depends on implementation strategies. Pre-PCV data from the AMB indicate high carriage rates of the pneumococcus, not only in infants but also in older children, and a risk of disease and death that spans lifetime. Post-PCV data highlight the protection of vaccinated children, but pneumococcal transmission remains important, resulting in a lack of indirect protection for unvaccinated persons.Areas covered: A non-systematic literature review focused on AMB countries. Relevant search terms were used in PubMed, and selected studies before and after PCV introduction were summarized narratively to appraise the suitability of current PCV programmatic strategies.Expert opinion: The current implementation strategy of PCV in the AMB appears suboptimal regarding the generation of indirect protection. We propose and discuss alternative programmatic strategies, including the implementation of broader age group mass campaigns, to accelerate disease control in this high transmission setting.

Frequency, Timing, Risk Factors, and Outcomes of Desaturation in Infants With Acute Bronchiolitis and Initially Normal Oxygen Saturation.

Importance: Little is known about the natural course of oxygen desaturation in acute bronchiolitis. Information on risk factors associated with desaturation as well as the time to desaturation in infants with bronchiolitis could help physicians better treat these infants before deciding whether to hospitalize them. Objective: To prospectively determine the frequency of desaturation in infants with bronchiolitis, along with the time to desaturation and risk factors associated with desaturation, and to compare infants who were hospitalized with those discharged home and evaluate risk factors for rehospitalization. Design, Setting, and Participants: This cohort study was conducted during the 2017 to 2018 and 2018 to 2019 respiratory syncytial virus seasons in a tertiary care pediatric emergency department in Switzerland. Included individuals were 239 otherwise-healthy infants aged younger than 1 year, diagnosed with acute bronchiolitis and oxygen saturation of 90% or more on arrival. Data were analyzed from July 2019 to October 2020. Exposures: After receiving triage care, study participants admitted to the emergency department were equipped with a pulse oximeter to continuously record oxygen saturation (Spo2 levels), regardless of subsequent hospitalization or discharge home. Main Outcomes and Measures: The primary outcome was desaturation (ie, Spo2 < 90%) during the first 36 hours. Results: Of 239 infants enrolled, with a median (interquartile range [IQR]) age of 3.9 (1.5-6.5) months, 116 (48.5%) were boys and desaturation occurred in 165 infants (69.0%). Median (IQR) time to desaturation was 3.6 (1.8-9.4) hours. The rate of desaturation was similar between infants hospitalized and those discharged home (137 of 200 infants [68.5%] vs 28 of 39 infants [71.8%]; difference, -3.3%; 95% CI, -18.8% to 12.2%; P = .85). A more severe initial clinical presentation with moderate or severe retractions was the only independent risk factor associated with desaturation (odds ratio, 2.73; 95% CI, 1.49 to 5.02; P = .001). Of 39 infants discharged home, 22 infants (56.4%) experienced major desaturations. However, infants with desaturations, including those with major desaturations, had rates of rehospitalization similar to those of infants without desaturations (8 of 28 infants [28.5%] vs 3 of 11 infants [27.3%]; difference, 1.2%; 95% CI, -29.9% to 32.5; P > .99). Conclusions and Relevance: These findings suggest that rates of desaturation in infants with acute bronchiolitis were high and similar between infants who were hospitalized and those discharged home. A more severe initial clinical presentation was the only risk factor associated with desaturation. However, for infants discharged home, desaturation was not a risk factor associated with rehospitalization.

Impact of 13-valent pneumococcal conjugate vaccine on the incidence of hospitalizations for all-cause pneumonia among children aged less than 5 years in Burkina Faso: An interrupted time-series analysis.

BACKGROUND: Pneumococcal disease is a major public health concern globally and particularly in Burkina Faso, where the 13-valent pneumococcal conjugate vaccine (PCV13) was introduced nationwide into the routine immunization schedule in 2013. The aim of this study was to evaluate vaccine impact on all-cause pneumonia hospitalizations among children <5 years of age. METHODS: Hospitalization data covering a 10-year period (January 1, 2009-December 31, 2018) were collected retrospectively in four rural district hospitals, using medical records to extract data on relevant variables. Using an interrupted time-series design and segmented regression, the effectiveness and impact of PCV13 on the rates of pneumonia hospitalization were estimated. Severe acute malnutrition and unintentional injury were used as control conditions. RESULTS: Vaccine effectiveness was found to be 34% (95% confidence interval (CI) 16-49%, p=0.001), 24% (95% CI 2-41%, p=0.032), and 50% (95% CI 30-64%, p<0.001) against all-cause pneumonia among children <5 years, <2 years, and 2-4 years of age, respectively. By October 2018, PCV13 introduction had led to an absolute reduction in the pneumonia hospitalization rate of 348 cases per 100000 person-years among children <5 years of age. No decline was observed for the control conditions. CONCLUSIONS: These estimates point to a substantial public health impact of PCV13 against pneumonia hospitalization among children aged <5 years in Burkina Faso.

Quality and reliability of vaccination documentation in the routine childhood immunization program in Burkina Faso: Results from a cross-sectional survey.

INTRODUCTION: Accurate and timely vaccination data are important to the Expanded Program on Immunization (EPI) to assess individual vaccination status and to monitor performance and vaccine coverage (VC). Since 2013, Burkina Faso introduced several new vaccines into the routine childhood immunization schedule. However, sustained efforts for a timely update and alignment of immunization home-based (HBRs) and health facility-based records (FBRs) with the evolving schedule were not implemented. METHODS: In 2016-17, we conducted a 6-week cross-sectional survey in 30 health facilities (HFs) across 10 health districts (HDs), targeting children aged < 24 months and their caregivers. Data collected included sociodemographics, availability of vaccination recording fields in HBRs, and vaccination dates. We evaluated the characteristics, completion patterns, and concordance of HBRs and FBRs to determine their reliability as data sources in estimating VC. A standard HBR was defined as one that had recording fields for all recommended 17 vaccine doses of the schedule, and discordance between HBR and FBR as having different vaccination dates recorded, or vaccination information missing in one of the records. We computed proportions and concordance statistics, and used logistic regression to explore predictors of discordance. RESULTS: We recruited 619 children, including 74% (n = 458) aged 0-11 months. Half (50.6%) of HBRs were non-standard. About two-thirds (64.6%) of children were concerned with discordant information. Compared to HBRs, FBRs were generally associated with low negative predictive values (median: 0.41; IQR: 0.16-0.70). Multivariate logistic regression model showed that standard HBR was protectively associated with discordant information (OR = 0.46, 95% CI: 0.26-0.81, p = 0.010). CONCLUSION: We documented a lack of standardization of HBRs and frequent information discordance with FBRs. There is a pressing need to update and standardize vaccination recording tools and ensure their continuous availability in HFs to improve data quality in Burkina Faso.

"Evaluation of a best practice approach to assess undergraduate clinical skills in Paediatrics".

BACKGROUND: The Objective Structured Clinical Examination (OSCE) has been used in pediatrics since the 1980s. Its main drawback is that large numbers of children are needed to make up for the fatigue factor inherent in prolonged testing periods. Also, examinations mainly include children between 7 and 16 years old. We describe the summative examination used in our institution to evaluate medical students' clinical competencies in pediatrics with realistic available resources and for a wider age-range. We also evaluated different factors known to influence medical students' performances. METHODS: This retrospective, descriptive, observational study evaluated the 740 distinct pediatric examination results of fourth-year medical students over 5 years. Their summative examination combined two different assessment methods: a structured real-patient examination (SRPE) using standardized assessment grids for the most frequent pediatric diagnoses, and a computer-based written examination (CBWE). RESULTS: Our approach defined an appropriate setting for some key elements of the educational objectives of pediatrics training, such as balancing the child-parent-pediatrician triangle and the ability to interact with pediatric patients, from newborns to 16-year-old adolescents, in a child-friendly fashion in realistic scenarios. SRPE scores showed no associations with students' degrees of exposure to specific lecture topics, vignettes, or bedside teaching. The impacts of clinical setting, topic, and individual examiners on SRPE scores was quite limited. Setting explained 1.6%, topic explained 4.5%, and examiner explained 4.7% of the overall variability in SRPE scores. CONCLUSIONS: By combining two different assessment methods, we were able to provide a best-practice approach for assessing clinical skills in Pediatrics over a wide range of real patients.

Enterovirus, parechovirus, adenovirus and herpes virus type 6 viraemia in fever without source.

OBJECTIVES: To evaluate the potential associations between fever without a source (FWS) in children and detection of human enterovirus (HEV), human parechovirus (HPeV), adenovirus (AdV) and human herpesvirus type 6 (HHV-6) in the plasma; and to assess whether the detection of viruses in the plasma is associated with a reduced risk of serious bacterial infection (SBI) and antibiotic use. DESIGN AND SETTING: Between November 2015 and December 2017, this prospective, single-centre, diagnostic study tested the plasma of children <3 years old with FWS. Real-time (reverse-transcription) PCR for HEV, HPeV, AdV and HHV-6 was used in addition to the standardised institutional work-up. A control cohort was also tested for the presence of viruses in their blood. RESULTS: HEV, HPeV, AdV and HHV-6 were tested for in the plasma of 135 patients of median age 2.4 months old. At least one virus was detected in 47 of 135 (34.8%): HEV in 14.1%, HHV-6 in 11.1%, HPeV in 5.9% and AdV in 5.2%. There was no difference in antibiotic use between patients with or without virus detected, despite a relative risk of 0.2 for an SBI among patients with viraemia. Controls were less frequently viraemic than children with FWS (6.0% vs 34.8%; p<0.001). CONCLUSIONS: HEV, HPeV, AdV and HHV-6 are frequently detected in the plasma of children with FWS. Antibiotic use was similar between viraemic and non-viraemic patients despite a lower risk of SBI among patients with viraemia. Point-of-care viral PCR testing of plasma might reduce antibiotic use and possibly investigations and admission rates in patients with FWS. TRIAL REGISTRATION NUMBER: NCT03224026.

A misleading appearance of a common disease: tuberculosis with generalized lymphadenopathy-a case report.

INTRODUCTION: Tuberculosis is a common illness for vulnerable populations in resource-limited settings. Lymph nodes in tuberculosis represent the most frequent extra-pulmonary form of tuberculosis in children, but lymph nodes are rarely generalized and large. We report an atypical pediatric case of tuberculosis with lymphadenopathy. Patient concerns and findings: A two-year-old child with severe acute malnutrition presented with painless, generalized, and excessively large nodes which were not compressive and were without fistula. Main diagnoses, interventions, outcomes: Fine needle aspiration was performed and led to the detection of lymph node granulomatous lymphadenitis suggestive of tuberculosis. CONCLUSION: The child was immediately initiated on anti-tuberculosis therapy with a very successful outcome. Clinicians should be aware of atypical manifestations such as the one we describe in the interest of swift diagnosis and initiation of treatment.

Can Professionalism Mini-Evaluation Exercise Scores Predict Medical Residency Performance? Validity Evidence Across Five Longitudinal Cohorts.

PURPOSE: The residency admissions process is a high-stakes assessment system with the purpose of identifying applicants who best meet standards of the residency program and the medical specialty. Prior studies have found that professionalism issues contribute significantly to residents in difficulty during training. This study examines the reliability (internal structure) and predictive (relations to other variables) validity evidence for a standardized patient (SP)-based Professionalism Mini-Evaluation Exercise (P-MEX) using longitudinal data from pediatrics candidates from admission to the end of the first year of postgraduate training. METHOD: Data from 5 cohorts from 2012 to 2016 (195 invited applicants) were analyzed from the University of Geneva (Switzerland) Pediatrics Residency Program. Generalizability theory was used to examine the reliability and variance components of the P-MEX scores, gathered across 3 cases. Correlations and mixed-effects regression analyses were used to examine the predictive utility of SP-based P-MEX scores (gathered as part of the admissions process) with rotation evaluation scores (obtained during the first year of residency). RESULTS: Generalizability was moderate (G coefficient = 0.52). Regression analyses predicting P-MEX scores to first-year rotation evaluations indicated significant standardized effect sizes for attitude and personality (ß = 0.36, P = .02), global evaluation (ß = 0.27, P = .048), and total evaluation scores (ß = 0.34, P = .04). CONCLUSIONS: Validity evidence supports the use of P-MEX scores as part of the admissions process to assess professionalism. P-MEX scores provide a snapshot of an applicant's level of professionalism and may predict performance during the first year of residency.

Comparison of long-menu and single-best-answer multiple choice questions in computer-based summative assessments: a randomised controlled trial.

BACKGROUND: Little is known regarding the psychometric properties of computerized long-menu formats in comparison to classic formats. We compared single-best-answer (Type A) and long-menu formats using identical question stems during the computer-based, summative, intermediate clinical-clerkship exams for nine disciplines. METHODS: In this randomised sequential trial, we assigned the examinees for every summative exam to either the Type A or long-menu format (four different experimental questions, otherwise identical). The primary outcome was the power of discrimination. The study was carried out at the Faculty of Medicine, University of Geneva, Switzerland, and included all the students enrolled for the exams that were part of the study. Examinees were surveyed about the long-menu format at the end of the trial. RESULTS: The trial was stopped for futility (p = 0.7948) after 22 exams including 88 experimental items. The long-menu format had a similar discriminatory power but was more difficult than the Type A format (71.45% vs 77.80%; p = 0.0001). Over half of the options (54.4%) chosen by the examinees in long-menu formats were not proposed as distractors in the Type A formats. Most examinees agreed that their reasoning strategy was different. CONCLUSIONS: In a non-selected population of examinees taking summative exams, long-menu questions have the same discriminatory power as classic Type A questions, but they are slightly more difficult. They are perceived to be closer to real practice, which could have a positive educational impact. We would recommend their use in the final years of the curriculum, within realistic key-feature problems, to assess clinical reasoning and patient management skills.

Effects of Blindfold on Leadership in Pediatric Resuscitation Simulation: A Randomized Trial.

Background: Pediatric resuscitations are rare events. Simulation-based training improves clinical and non-clinical skills, as well as survival rate. We assessed the effectiveness of using blindfolds to further improve leadership skills in pediatric simulation-based training. Methods: Twelve teams, each composed of 1 pediatric emergency fellow, 1 pediatric resident, and 2 pediatric emergency nurses, were randomly assigned to the blindfold group (BG) or to the control group (CG). All groups participated in one session of five simulation-based resuscitation scenarios. The intervention was using a blindfold for the BG leader for the scenarios B, C, and D. Three evaluators, who were blinded to the allocation, assessed leadership skills on the first and last video-recorded scenarios (A and E). Questionnaires assessed self-reported changes in stress and satisfaction about skills after the first and the last scenarios. Results: Improvement in leadership skills doubled in the BG compared with the CG (11.4 vs. 5.4%, p = 0.04), whereas there was no increase in stress or decrease in satisfaction. Conclusion: Blindfold could be an efficient method for leadership training during pediatric resuscitation simulated scenarios. Future studies should further assess its effect at a follow-up and on clinical outcomes after pediatric resuscitation.

[InfoKids: changing the patients' journey paradigm in an Emergency Department]. / InfoKids : changement de paradigme du parcours patients dans un service d'urgences.

Nowadays, citizens are little supported to decide whether they should consult the Emergency Departments (ED) in case of illness or trauma. Moreover, once in the ED, they often must deal with overcrowding, long waiting times, the acute nature of the visits, administrative data management, and a lack of follow-up after the visit. To improve this situation, we have developed an e-health solution delivering a more patient-centered experience by connecting patients, caregivers, and administrative clerks through a web and mobile applications. This innovative system is intended to improve the entire emergency care process, facilitating the caregiver and administrative work and supporting patients before, during, and after their ED consultation.

De nos jours, les citoyens sont peu soutenus en cas de maladie ou de traumatisme pour décider si leur état de santé justifie une consultation aux urgences. Arrivés aux urgences, les patients doivent faire face à des délais d'attente, au stress engendré par une urgence médicale et au manque d'information concernant le suivi à domicile. Afin d'améliorer cette situation, nous avons développé une solution d'e-santé, composée d'applications web et mobiles, guidant le patient de manière personnalisée tout au long de son parcours et connectant patients, soignants et employés administratifs. Ce système novateur améliore l'ensemble du processus de soins d'urgence en facilitant le travail des soignants, des administratifs et en soutenant les patients avant, pendant et après leurs consultations aux urgences.