Impact of a collaborative childhood anaemia intervention programme in Peru.

OBJECTIVES: To evaluate the impact of a 12-month multi-modal public health intervention programme for treating and preventing anaemia among children aged 6 months to 4 years in an underserved community in Peru. METHODS: The intervention included nutritional education, use of a Lucky Iron Fish® cooking tool, and dietary supplementation. The primary outcome measure was anaemia resolution. Secondary outcomes included absolute changes in haemoglobin, change in knowledge survey scores and adherence to interventions. Chi-square test and Mann-Whitney U-test were employed to identify associations between anaemia and intervention-related measures. Variables found to be significantly associated in bivariate analysis or of clinical importance were included in a logistic regression model. RESULTS: Of the 406 children enrolled, 256 (63.1%) completed the programme. Of those, 34.0% had anaemia at baseline; this decreased to 13.0% over 12 months. The mean haemoglobin for all ages at baseline was 11.3 g/dL (SD 0.9). At 12 months, the mean was 11.9 g/dL (SD 0.8), with a mean increase of 0.5 g/dL (95% CI 0.4-0.6). Children with anaemia at baseline saw an increase of 1.19 g/dL at the 12-month follow-up (95% CI 1.12-1.37). Parents correctly answered 79.0% of knowledge assessment questions at baseline, which increased to 86.6% at 12 months. CONCLUSIONS: We observed a reduction in the prevalence of mild to moderate anaemia among study participants in this vulnerable population and conclude that multi-modal intervention programmes providing nutrition education in conjunction with low-cost iron supplementation and easy-to-use Lucky Iron Fish® cooking tools may reduce and prevent anaemia in children.

Features of COVID-19 post-infectious cytokine release syndrome in children presenting to the emergency department.

The 2019 coronavirus disease (COVID-19) has not appeared to affect children as severely as adults. However, approximately 1 month after the COVID-19 peak in New York City in April 2020, cases of children with prolonged fevers abruptly developing inflammatory shock-like states have been reported in Western Europe and the United States. This case series describes four previously healthy children with COVID-19 infection confirmed by serologic antibody testing, but negative by nasopharyngeal RT-PCR swab, presenting to the Pediatric Emergency Department (PED) with prolonged fever (5 or more days) and abrupt onset of hemodynamic instability with elevated serologic inflammatory markers and cytokine levels (IL-6, IL-8 and TNF-α). Emergency physicians must maintain a high clinical suspicion for this COVID-19 associated post-infectious cytokine release syndrome, with features that overlap with Kawasaki Disease (KD) and Toxic Shock Syndrome (TSS) in children with recent or current COVID-19 infection, as patients can decompensate quickly.

Accuracy of Remote Interpretation of Pediatric Emergency Ultrasound Over Third Generation Networks Across Continents.

OBJECTIVE: This study aimed to evaluate live-stream videos for evaluation of pediatric emergency medicine ultrasound using a third generation (3G) network. METHODS: The interrater reliability of a remote 3G network live-streaming assessment of ultrasound scans for abdominal free fluid, intussusception, and hip effusions was evaluated. Fifty-eight deidentified 6-second video clips in .mp4 format of focused assessment with sonography in trauma scans were downloaded to a laptop. A "bedside" ultrasound expert evaluated each scan and marked it positive or negative for the presence of free fluid. Using an iPhone 3G, Skype was used to connect to the second ultrasound expert located in Addis Ababa, Ethiopia, who reviewed the same scans. When the remote expert returned to the United States, evaluation of the scans was repeated as a second bedside reviewer. Interrater reliability was assessed using the κ statistic and percent agreement. This process was repeated for 44 intussusception scans and 28 hip effusion scans. RESULTS: The κ values (95% confidence interval) between the bedside and remote evaluators for focused assessment with sonography in trauma, intussusception, and hip effusion were 0.748 (0.576-0.92), 0.816 (0.648-0.984), and 0.764 (0.519-1.0), respectively. The percent agreements after adjusting for chance were 86%, 80%, and 88%, respectively. The κ values between the bedside assessments by each evaluator were 0.851 (0.71-0.992), 0.8 (0.616-0.984), and 0.747 (0.479-0.884), respectively. The percent agreements after adjusting for chance were 92%, 81%, and 88%, respectively. CONCLUSIONS: Live-stream video conference using cellphones over 3G network is a feasible and accurate method for consultation of ultrasound scans from a remote location.

Evaluation of a Modified Objective Structured Assessment of Technical Skills Tool for the Assessment of Pediatric Laceration Repair Performance.

Introduction The Accreditation Council for Graduate Medical Education (ACGME) has developed milestones including procedural skills under the core competency of patient care. Progress in training is expected to be monitored by residency programs. To our knowledge, there exists no tool to evaluate pediatric resident laceration repair performance. Methods The Objective Structured Assessment of Technical Skills was adapted to evaluate resident laceration repair performance using two components: a global rating scale (GRS) and a checklist. Pediatric and family medicine residents at a tertiary care children's hospital were filmed performing a simulated laceration repair. Videos were evaluated by at least five physicians trained in laceration repair. Concordance correlation coefficients (CCC) were calculated for the GRS and checklist scores. Scores for each resident were compared across levels of training and procedural experience. Spearman's rank order correlations were calculated to compare the checklist and GRS. Results Thirty residents were filmed performing laceration repair procedures. The CCC showed fair concordance across reviewers for the checklist (0.55, 95% CI: 0.38-0.69) and the GRS (0.53, 95% CI: 0.36-0.67). There was no significant difference in scores by self-reported experience or training level. There was correlation between the median GRS and checklist scores (Spearman ρ = 0.730, p < .001). Conclusions A novel tool to evaluate resident laceration repair performance in a pediatric emergency department showed fair agreement across reviewers. The study tool is not precise enough for summative evaluation; however, it can be used to distinguish between trainees who have and have not attained competence in laceration repair for formative feedback.

Vascular Access in Pediatric Patients in the Emergency Department: Types of Access, Indications, and Complications.

Vascular access is a potentially life-saving procedure that is a mainstay of emergency medicine practice. There are a number of challenges associated with obtaining and maintaining vascular access, and the choice of the route of access and equipment used will depend on patient- and provider-specific factors. In this issue, the indications and complications of peripheral intravenous access, intraosseous access, and central venous access are reviewed. Timely and effective assessment and management of difficult-access patients, pain control techniques that can assist vascular access, and contraindications to each type of vascular access are also discussed.

Cost-effectiveness of point-of-care testing for dehydration in the pediatric ED.

OBJECTIVES: Acute gastroenteritis (AGE) and subsequent dehydration account for a large proportion of pediatric emergency department (PED) visits. Point-of-care (POC) testing has been used in conjunction with clinical assessment to determine the degree of dehydration. Despite the wide acceptance of POC testing, little formal cost-effective analysis of POC testing in the PED exists. We aim to examine the cost-effectiveness of using POC electrolyte testing vs traditional serum chemistry testing in the PED for children with AGE. METHODS: This was a cost-effective analysis using data from a randomized control trial of children with AGE. A decision analysis model was constructed to calculate cost-savings from the point of view of the payer and the provider. We used parameters obtained from the trial, including cost of testing, admission rates, cost of admission, and length of stay. Sensitivity analyses were performed to evaluate the stability of our model. RESULTS: Using the data set of 225 subjects, POC testing results in a cost savings of $303.30 per patient compared with traditional serum testing from the point of the view of the payer. From the point-of-view of the provider, POC testing results in consistent mean savings of $36.32 ($8.29-$64.35) per patient. Sensitivity analyses demonstrated the stability of the model and consistent savings. CONCLUSIONS: This decision analysis provides evidence that POC testing in children with gastroenteritis-related moderate dehydration results in significant cost savings from the points of view of payers and providers compared to traditional serum chemistry testing.

On Shaky Ground: Learner Response and Confidence After Tabletop Earthquake Simulation.

OBJECTIVE: The aim of this study was to evaluate residents' confidence and attitudes related to management of earthquake victims during a tabletop simulation and 6 months after the intervention. METHODS: Pediatric residents from 4 training programs were recruited via e-mail. The tabletop simulation involved 3 pediatric patients (crush injury, head injury, and a nonverbal patient with minor injuries). A facilitated debriefing took place after the simulation. The same simulation was repeated 6 months later. A survey was administered before the simulation, immediately after, and after the 6-month repeat simulation to determine participants' self-rated confidence and willingness to respond in the event of a disaster. A 5-point Likert scale that ranged through novice, advanced beginner, competent, proficient, and expert was used. RESULTS: Ninety-nine participants completed the survey before the initial simulation session. Fifty-one residents completed the immediate postsurvey, and 75 completed the 6-month postsurvey. There was a statistically significant improvement in self-rated confidence identifying and managing victims of earthquake disasters after participating in the simulation, with 3% rating themselves as competent on the presurvey and 33% rating themselves as competent on the postsurvey (P < 0.05). There was a nonstatistically significant improvement in confidence treating suspected traumatic head injury as well as willingness to deploy to both domestic and international disasters. CONCLUSIONS: Tabletop simulation can improve resident comfort level with rare events, such as caring for children in the aftermath of an earthquake. Tabletop can also be easily integrated into resident curriculum and may be an effective way to provide disaster medical response training for trainees.

Diffuse corneal abrasion after ocular exposure to laundry detergent pod.

Although ocular injury from alkaline household cleaning products is well described, there is less known about the significance and extent of injury with ocular exposure to detergent pods. We report a 12-month-old with diffuse corneal abrasion caused by ocular contact with a laundry detergent pod. In addition to the known risks with aspiration with detergent pods, the potential for severe ocular injury is important for parents and clinicians to recognize. Children with ocular exposure to detergent pods should seek immediate medical care.

Checklist use in evaluating pediatric disaster training.

OBJECTIVE: Disaster preparedness training has a small but growing part in medical education. Various strategies have been used to simulate disaster scenarios to safely provide such training. However, a modality to compare their effectiveness is lacking. The authors propose the use of checklists, which have been a standard in aviation safety for decades. DESIGN: Residents at four different academic pediatric residency programs volunteered to participate in tabletop simulation of a timed, pediatric disaster scenario. Resident teams were required to properly triage and manage simulated patients. Care intervention requests corresponding to each of the patients were recorded on a premade checklist. RESULTS: Thirty-six teams provided a total of 1,476 possible care intervention requests for three pediatric patients: one with crush injury, one with increased intracranial pressure, and a nonverbal child. Some interventions were more likely to be omitted than others, and some teams performed extra interventions. Twenty-five entries from the checklist intervention responses were missing, affecting three of the teams. On average, teams requested 65 percent, were prompted to request 11 percent, and missed 22 percent of all checklist interventions with only 2 percent of all items not being recorded. Chi-square tests were performed for each patient scenario using R software. Categories compared included total counts of "requested," "prompted," and "missed" responses. Chi-square values were all statistically significant (p value < 0.05). CONCLUSIONS: In the checklist use during a tabletop disaster simulation, the authors have demonstrated that the checklist allows trainees to receive near immediate feedback. This training exercise provided them an opportunity to explore their own preparedness for a disaster scenario in a low-stress environment and allows for evaluation of such preparedness in a safe environment.

Individual Physician versus Team-Based Medical Encounters: Maximizing the Efficiency of a Medical Relief Service in Rural Honduras.

Background. For several years, the Virginia Commonwealth University (VCU) Department of Internal Medicine has traveled to the towns of La Hicaca and Coyoles in rural Honduras. In 2010, a new encounter method was employed during the brigade in Coyoles. Objectives. To examine the differences in clinical encounters and adherence with chronic diseases and public health screening between the traditional and team-based encounter methods. Methods. Chi-square analysis was used to determine statistical significance between encounter methods over several variables used in the standard interview form. Results. 314 patients were interviewed using the team-based approach, and 153 patients were interviewed with the traditional model. Statistically significant increases in compliance using the team-based method were observed with diabetes screening and selecting candidacy for antihelminthic therapy. Other variables with significantly increased compliance using the team-based method were compliance with checking a blood glucose value, diagnosing GERD, and prescribing medication such as analgesics and multivitamins. Conclusion. Our results show a statistically significant increase in compliance with data collection and clinical screening using the new team-based encounter method. This design provides a more goal-oriented approach to the patient interview. These data will help guide more effective delivery of health care on future medical relief trips to Honduras.