Reinforcing outpatient medical student learning using brief computer tutorials: the Patient-Teacher-Tutorial sequence

BACKGROUND

At present, what students read after an outpatient encounter is largely left up to them. Our objective was to evaluate the education efficacy of a clinical education model in which the student moves through a sequence that includes immediately reinforcing their learning using a specifically designed computer tutorial.

METHODS

Prior to a 14-day Pediatric Emergency rotation, medical students completed pre-tests for two common pediatric topics: Oral Rehydration Solutions (ORS) and Fever Without Source (FWS). After encountering a patient with either FWS or a patient needing ORS, the student logged into a computer that randomly assigned them to either a) completing a relevant computer tutorial (e.g. FWS patient + FWS tutorial = "in sequence") or b) completing the non-relevant tutorial (e.g. FWS patient + ORS tutorial = "out of sequence"). At the end of their rotation, they were tested again on both topics. Our main outcome was post-test scores on a given tutorial topic, contrasted by whether done in- or out-of-sequence.

RESULTS

Ninety-two students completed the study protocol with 41 in the 'in sequence' group. Pre-test scores did not differ significantly. Overall, doing a computer tutorial in sequence resulted in significantly greater post-test scores (z-score 1.1 (SD 0.70) in sequence vs. 0.52 (1.1) out-of-sequence; 95% CI for difference +0.16, +0.93). Students spent longer on the tutorials when they were done in sequence (12.1 min (SD 7.3) vs. 10.5 (6.5)) though the difference was not statistically significant (95% CI diff: -1.2 min, +4.5).

CONCLUSIONS

Outpatient learning frameworks could be structured to take best advantage of the heightened learning potential created by patient encounters. We propose the Patient-Teacher-Tutorial sequence as a framework for organizing learning in outpatient clinical settings.

Community case management of childhood diarrhea in a setting with declining use of oral rehydration therapy: findings from cross-sectional studies among primary household caregivers, Kenya, 2007

We sought to determine factors associated with appropriate diarrhea case management in Kenya. We conducted a cross-sectional survey of caregivers of children < 5 years of age with diarrhea in rural Asembo and urban Kibera. In Asembo, 61% of respondents provided oral rehydration therapy (ORT), 45% oral rehydration solution (ORS), and 64% continued feeding. In Kibera, 75% provided ORT, 43% ORS, and 46% continued feeding. Seeking care at a health facility, risk perception regarding death from diarrhea, and treating a child with oral medications were associated with ORT and ORS use. Availability of oral medication was negatively associated. A minority of caregivers reported that ORS is available in nearby shops. In Kenya, household case management of diarrhea remains inadequate for a substantial proportion of children. Health workers have a critical role in empowering caregivers regarding early treatment with ORT and continued feeding. Increasing community ORS availability is essential to improving diarrhea management.

[Acute infantile diarrhea treated with infantile Tuina: a multicentre randomized controlled trial]

OBJECTIVE

To generalize the application of Tuina in treating infantile diseases and evaluate the validity and safety of Tuina.

METHODS

By a multicentre randomized controlled study, 240 patients were randomly divided into an observation group (n = 180) and a control group (n = 60). The observation group was treated by tonifying Pijing and clarifying Dachangjing, and Tuina on Lanmen, Qi, Fu Shangqijiegu, Guiwei and Zusanli (ST 36), etc. Banmen and Sanguan were used as the supplementary point according to the syndrome differentiation. The control group was treated by oral administration of Smecta. After 5 day treatments, Chinese syndrome score and the clinical effect were evaluated.

RESULTS

After the third and fifth treatment, the Chinese syndrome score of both groups descended obviously. The decline of the observation group was superior to that of the control group (all P < 0.01). The cured rate of 75.6% (136/180) in the observation group was better than 21.7% (13/60) in the control group (P < 0.001). The clinical cured rate of 95.0% (171/180) according to Chinese syndrome score in the observation group was better than 58.3% (35/60) in the control group (P < 0.001). There was no adverse reaction in both groups.

CONCLUSION

Infantile Tuina has a better therapeutic effect in the treatment of acute infantile diarrhea than oral administration of Smecta.

Cost-effectiveness of improving pediatric hospital care in Nicaragua

OBJECTIVE

To determine the costs and cost-effectiveness of an intervention to improve quality of care for children with diarrhea or pneumonia in 14 hospitals in Nicaragua, based on expenditure data and impact measures.

METHODS

Hospital length of stay (LOS) and deaths were abstracted from a random sample of 1294 clinical records completed at seven of the 14 participating hospitals before the intervention (2003) and 1505 records completed after two years of intervention implementation ("post-intervention"; 2006). Disability-adjusted life years (DALYs) were derived from outcome data. Hospitalization costs were calculated based on hospital and Ministry of Health records and private sector data. Intervention costs came from project accounting records. Decision-tree analysis was used to calculate incremental cost-effectiveness.

RESULTS

Average LOS decreased from 3.87 and 4.23 days pre-intervention to 3.55 and 3.94 days post-intervention for diarrhea (P = 0.078) and pneumonia (P = 0.055), respectively. Case fatalities decreased from 45/10 000 and 34/10 000 pre-intervention to 30/10 000 and 27/10 000 post-intervention for diarrhea (P = 0.062) and pneumonia (P = 0.37), respectively. Average total hospitalization and antibiotic costs for both diagnoses were US$ 451 (95% credibility interval [CI]: US$ 419-US$ 482) pre-intervention and US$ 437 (95% CI: US$ 402-US$ 464) post-intervention. The intervention was cost-saving in terms of DALYs (95% CI: -US$ 522- US$ 32 per DALY averted) and cost US$ 21 per hospital day averted (95% CI: -US$ 45- US$ 204).

CONCLUSIONS

After two years of intervention implementation, LOS and deaths for diarrhea decreased, along with LOS for pneumonia, with no increase in hospitalization costs. If these changes were entirely attributable to the intervention, it would be cost-saving.

[Congenital diarrhoea]

Congenital diarrhoea of heterogenic etiology is a rare cause of chronic diarrhoea. Characteristic features are: onset in the first weeks of life, life-threatening severe dehydratation and electrolyte disorders leading to a necessity of long-term parenteral nutrition. The clinical onset may be delayed and the degree of diarrhoea may be modest, making the diagnosis difficult. The main causes of congenital diarrhoea such as intestine electrolytes, carbohydrates, lipid and protein transport disorders and congenital enzymatic deficiencies, enterocyte polarization disorders, hormonal, immunological, metabolic, genetic and congenital anatomic disorders are presented in the paper. Some of them, such as: microvillus inclusion disease, tufting enteropathy, intestinal anedocrynosis, IPEX syndrome (immunodysregulation polyendocrinopathy enteropathy X-linked syndrome) have been described recently. One of the basic investigations, when congenital diarrhea is suspected, is general examination of the stool, its electrolyte concentration and serum electrolytes and blood gas analysis. Often, small bowel biopsy with histological examination (with the use of electronic microscopy and PAS staining) is indicated. In some cases molecular examination is possible and indicated. In differential diagnosis other, more frequent causes of chronic diarrhea of infancy, have to be excluded. In most of the cases of congenital diarrhoea there is no casual treatment available - usually long-term parenteral nutrition is necessary.

Evaluation of a social marketing intervention promoting oral rehydration salts in Burundi

BACKGROUND

Diarrhea is the second leading cause of death for children under five in Burundi; however, use of oral rehydration salts (ORS), the recommended first-line treatment, remains low. In 2004, PSI/Burundi launched a social marketing intervention to promote ORASEL among caregivers of children under five; the product was relaunched in 2006 with a new flavor. This study evaluates the intervention after the ORASEL relaunch, which included mass media and interpersonal communication activities. The study looks at trends in ORASEL use in Burundi and in behavioral determinants that may be related to its use.

METHODS

In 2006 and 2007, PSI conducted household surveys among Burundian females of reproductive age (15-49). Both surveys used a two-stage sampling process to select 30 households in each of 115 rural and urban collines throughout the nation. Survey respondents were asked about diarrhea treatment-related behavior; key behavioral determinants; and exposure to the ORASEL intervention. Data were analyzed to identify trends over time, characteristics of ORASEL users, and associations between exposure to the intervention and changes in ORASEL use and related behavioral determinants.

RESULTS

ORASEL use among caregivers at their children's last diarrheal episode increased significantly from 20% in 2006 to 30% in 2007, and there were also desirable changes in several behavioral determinants associated with ORASEL use. Evaluation analysis showed that a higher level of exposure to the social marketing campaign was associated with greater use of ORASEL and with significant improvements in perceived availability, knowledge of the signs of diarrhea and dehydration, social support, and self-efficacy.

CONCLUSIONS

ORS use can be improved through social marketing and educational campaigns that make the public aware of the availability of the product, encourage dialogue about its use, and increase skills and confidence relating to correct product preparation and administration. Further interventions in Burundi and elsewhere should promote ORS through a variety of mass media and interpersonal communication channels, and should be rigorously evaluated in the context of the total market for diarrhea treatment products.

Effectiveness of packed rice-oral rehydration solution among children with acute watery diarrhea

OBJECTIVE

This study aims to compare the effectiveness between the packed rice-oral rehydration solution (R-ORS) and the glucose-based oral rehydration solution (G-ORS) in children with acute watery diarrhea.

MATERIAL AND METHOD

Randomized control trial was conducted to compare duration of diarrhea, stool frequency, incremental weight gain, intravenous fluid requirement, and duration of admission. Subjects were 70 pediatric patients (9-60 months-old) and were equally divided into two groups (n=35 for each): treatment group (with R-ORS treatment) and control group (with G-ORS treatment). The data were collected during January 1, 2007 to January 2008. All patients were treated with oral rehydration therapy within first 4 hours of admission. Intravenous rehydration was also scheduled. Both groups were fed with rice gruel or lactose-free formula as tolerated.

RESULTS

Using survival analysis, both duration of diarrhea and admission was significantly shortened in the treatment group compared to the control group. (27.5 hrs. vs. 40.5 hrs: p = 0.01 and 40.1 hrs. vs. 56.0 hrs: p = 0.02 respectively). However, stool frequency, incremental weight gain and intravenous fluid requirement between the two groups remained insignificantly different.

CONCLUSION

R-ORS was more effective in the management of acute watery diarrhea in children. Duration of diarrhea and treatment was shortened when compared to G-ORS.

Performance of a community-based health and nutrition-education intervention in the management of diarrhoea in a slum of Delhi, India

Diarrhoeal infections are the fifth leading cause of death worldwide and continue to take a high toll on child health. Mushrooming of slums due to continuous urbanization has made diarrhoea one of the biggest public-health challenges in metropolitan cities in India. The objective of the study was to carry out a community-based health and nutrition-education intervention, focusing on several factors influencing child health with special emphasis on diarrhoea, in a slum of Delhi, India. Mothers (n=370) of children, aged >12-71 months, identified by a door-to-door survey from a large urban slum, were enrolled in the study in two groups, i.e. control and intervention. To ensure minimal group interaction, enrollment for the control and intervention groups was done purposively from two extreme ends of the slum cluster. Baseline assessment of knowledge, attitudes, and practices on diarrhoea-related issues, such as oral rehydration therapy (ORT), oral rehydration salt (ORS), and continuation of breastfeeding during diarrhoea, was carried out using a pretested questionnaire. Thereafter, mothers (n=195) from the intervention area were provided health and nutrition education through fortnightly contacts achieved by two approaches developed for the study--'personal discussion sessions' and 'lane approach'. The mothers (n=175) from the control area were not contacted. After the intervention, there was a significant (p=0.000) improvement in acquaintance to the term 'ORS' (65-98%), along with its method of reconstitution from packets (13-69%); preparation of home-made sugar-salt solution (10-74%); role of both in the prevention of dehydration (30-74%) and importance of their daily preparation (74-96%); and continuation of breastfeeding during diarrhoea (47-90%) in the intervention area. Sensitivity about age-specific feeding of ORS also improved significantly (p=0.000) from 13% to 88%. The reported usage of ORS packets and sugar-salt solution improved significantly from 12% to 65% (p=0.000) and 12% to 75% (p=0.005) respectively. The results showed that health and nutrition-education intervention improved the knowledge and attitudes of mothers. The results indicate a need for intensive programmes, especially directed towards urban slums to further improve the usage of oral rehydration therapy.

Greater years of maternal schooling and higher scores on academic achievement tests are independently associated with improved management of child diarrhea by rural Guatemalan mothers

Appropriate home management can alleviate many of the consequences of diarrhea including malnutrition, impaired development, growth faltering, and mortality. Maternal cognitive ability, years of schooling, and acquired academic skills are hypothesized to improve child health by improving maternal child care practices, such as illness management. Using information collected longitudinally in 1996-1999 from 466 rural Guatemalan women with children <36 months, we examined the independent associations between maternal years of schooling, academic skills, and scores on the Raven's Progressive Matrices and an illness management index (IMI). Women scoring in the lowest and middle tertiles of academic skills scored lower on the IMI compared to women in the highest tertile (-0.24 [95% CI: -0.54, 0.07]; -0.30 [95% CI: -0.54, -0.06], respectively) independent of sociodemographic factors, schooling, and Raven's scores. Among mothers with less than 1 year of schooling, scoring in the lowest tertile on the Raven's Progressive Matrices compared to the highest was significantly associated with scoring one point lower on the IMI (-1.18 [95% CI: -2.20, -0.17]). Greater academic skills were independently associated with maternal care during episodes of infant diarrhea. Schooling of young girls and/or community based programs that provide women with academic skills such as literacy, numeracy and knowledge could potentially improve mothers' care giving practices.

How do pharmacists manage acute diarrhoea in an 8-month-old baby? A simulated client study

OBJECTIVES

Community pharmacists claim a role in health care based on their added value as counsellors and providers of pharmaceutical care. The aim of this study was to assess to what extent they fulfil this role with respect to the management of acute diarrhoea in an 8-month-old baby. METHODS In February 2008, two female simulated clients of 55 and 35 years old visited 101 Belgian pharmacies. Both entered the pharmacy and said: 'I'm here for my grandchild/ my sister's baby. She has diarrhoea.' They only provided more information if the pharmacist asked for it. All the questions and the verbal advice provided by the pharmacist were audio-recorded and the suggested medicines were registered.

KEY FINDINGS

One pharmacist did not ask any questions. All the other pharmacists asked the age of the child, 19% asked how long the symptoms had been on-going, 27% asked whether the baby had a fever and 24% inquired about vomiting. Seventy-five per cent of the pharmacists emphasized the importance of sufficient fluid intake and/or the risk of dehydration, while 4% described how to recognize such dehydration symptoms. Oral rehydration solution was suggested by 30% of the pharmacists, while 86% suggested the yeast probiotic Saccharomyces boulardii. Of the 28% spontaneously giving dietary advice, no-one said that normal feeding should restart 'as soon as possible'. Thirty-one per cent advised consulting a doctor, either immediately or in the case of the symptoms not improving after a while.

CONCLUSIONS

Apart from inquiring about the child's age, the majority of pharmacists asked too few questions to be able to analyse the situation properly. Ample information was provided on the risk of dehydration, but counselling on the suggested medicines was insufficient.

[Efficiency of lactose-free formula feeding as an adjunctive therapy in infants with acute diarrhea]

OBJECTIVE

To study the efficiency of lactose-free formula feeding as an adjunctive therapy in infants with acute diarrhea.

METHODS

A rigorous double-blind, randomized, controlled equivalence trial was performed. One hundred and twenty infants with acute diarrhea were randomly divided into two groups: lactose-free formula and conventional formula feeding. The two groups were given conventional medical treatment and oral rehydration therapy. The therapeutic effects were observed 1 week after treatment.

RESULTS

The cure rate and the total effective rate were 58.3% and 96.7% respectively in the lactose-free formula group, and they were 8.3% and 85.0% respectively in the conventional formula group. There were significant differences in the therapeutic effect between the two groups (p<0.05). The duration of diarrhea remission (3.17+/-1.04 days) in the lactose-free formula group was significantly shorter than that in the conventional formula group (5.25+/-1.58 days) (p<0.05). After treatment the incidence of fecal flora disturbance was lower in the lactose-free formula group than that in the conventional formula group (p<0.05). No aderverse events were observed in the two groups.

CONCLUSIONS

Lactose-free formula feeding together with conventional therapy can significantly shorten the disease course and improve the treatment outcome in infants with acute diarrhea.

Prevention and management of gastrointestinal infections in infants from a nutritional perspective

This article considers infections of the gastrointestinal (GI) tract. This is a complex organ, which exists in a range of environments. Despite containing defence mechanisms against microorganisms, GI infections are common throughout infancy; however, the risk of infection can be reduced through careful hygiene and the encouragement of breast-feeding. Although research into the role of dietary factors in preventing or treating GI infection is in its early days, there is some evidence for the use of prebiotics and probiotics. The role of health care professionals is to give parents and carers advice to manage these infections, and to differentiate those infants at risk of dehydration, or those where diarrhoea and vomiting signifies something more serious. Informing parents and carers about the treatment and management of minor ailments will also help avoid unnecessary demand on the health service associated with regular consultation about these conditions.

Resource utilization and costs of treating severe rotavirus diarrhea in young Mexican children from the health care provider perspective

BACKGROUND

Rotavirus is the most common cause of severe diarrhea in infants. The economic costs of treating severe rotavirus can be quite significant and are important to include in any evaluation of prevention programs. The aim of this study was to determine utilization of health care resources and costs incurred due to severe diarrhea associated with rotavirus infection in Mexican children < 5 years of age.

MATERIAL AND METHODS

The costs of rotavirus infection evaluated in this observational study consisted of hospital, emergency room care and out-patient visit expenses at three hospitals of the Mexican Institute of Social Security throughout 1999-2000. Service costs were estimated from costs of care for rotavirus versus non-rotavirus diarrhea obtained through a follow-up study data of 383 children and administrative records.

RESULTS

Diarrhea cases due to rotavirus infection comprised 36% of the sample. Participants with rotavirus diarrhea spent an average of 3.2 days in the hospital, 5.9 hours in the emergency room, and had 1.3 visits to an outpatient physician's office. Some differences in the consumption of health care were found between rotavirus and non-rotavirus diarrhea cases, although the mean costs of rotavirus and nonrotavirus cases were not significantly different. The mean cost per case of severe rotavirus diarrhea was estimated to be US $936. The total cost of treating severe rotavirus diarrhea, including 5,955 rotavirus hospitalizations for 2004, was estimated at US $5.5 million.

CONCLUSION

Health care costs due to treatment for severe rotavirus diarrhea are a significant economic burden to the Mexican Social Security system.

Metchnikoff and the centenary of probiotics: an update of their use in gastroenteric pathology during the age of development

Acute gastroenteritis, antibiotic-associated diarrhea, diarrhea due to Clostridium difficile and traveller's diarrhea, Helicobacter pylori infection and intestinal inflammatory diseases are primitive and/or secondary pathological conditions that alter the intestinal mucosa and microbiota. For years researchers have searched for solutions to restore and rebalance normal transit and intestinal flora. Elia Metchnikoff was the first one to introduce oral bacteriotherapy, that uses very efficient microorganisms that prevent putrefaction and aging. Oral bacteriotherapy has now evolved in probiotics, whose helpful action to prevent and treat some gastroenteric pathologies is currently being studied.

[Multi-central randomized controlled investigation on the massage for supplementing qi and removing obstruction in the Governor Vessel for treatment of infantile diarrhea due to spleen deficiency]

OBJECTIVE

To make multi-central clinical evaluation of the massage for supplementing qi and removing obstruction in the Governor Vessel for treatment of infantile diarrhea due to spleen deficiency.

METHODS

By using multi-central, randomized and controlled method, 275 cases were randomly divided into an observation group (n = 137) and a control group (n = 138). The observation group were treated by the massage for supplementing qi and removing obstruction in the Governor Vessel, and the control group by routine massage therapy in Tuina Science, a teaching material for college and school of TCM. After treatment for 7 days, their therapeutic effects were compared.

RESULTS

The cured rate was 83.2% in the observation group and 69.6% in the control group with a signifi cant difference between the two groups (P < 0.05), the former being better than the latter. The mean cured time was (3.22 +/- 1.04) days in the observation group and (4.20 +/- 1.11) days in the control group with a significant difference between the two groups (P < 0.05), the former being shorter than the latter.

CONCLUSION

The massage for supplementing qi and removing obstruction in the Governor Vessel has a definite therapeutic effect on infantile diarrhea due to spleen deficiency, with rapid effect.

Enterotoxigenic Escherichia coli (ETEC): a recurring decimal in infants' and travelers' diarrhea

Enterotoxigenic Escherichia coli (ETEC) is an important cause of diarrhea in infants and in travelers from developed to underdeveloped countries, especially in regions of poor sanitation. The ETEC are acquired by the ingestion of contaminated food and water, and adults living in endemic areas develop immunity. The disease condition manifests as a minor discomfort to a severe cholera-like syndrome and requires colonization by the microorganism and the elaboration of one or more enterotoxins. The ETEC attach to the epithelial cells of the gastrointestinal tract and release substances that affect the normal functioning of the tract, thereby resulting in diarrhea, and subsequently millions of deaths everyday, particularly in children. The prevention of the spread of this strain of diarrheagenic E. coli depends on ensuring appropriate sanitary measures; hand-washing and proper preparation of food; chlorination of water supplies; and appropriate sewage treatment and disposal. Parenteral or oral fluid and electrolyte replacement is used to prevent dehydration, and broad-spectrum antibiotics are used in chronic or life-threatening cases, but in most cases, should be avoided because of severe side effects.

[Clinical observation on drug-separated moxibustion at Shenque (CV 8) for treatment of infantile autumn diarrhea]

OBJECTIVE

To observe therapeutic effect of drug-separated moxibustion at Shenque (CV 8) for treatment of infantile autumn diarrhea.

METHODS

One hundred and thirty-six cases were randomly divided into an obser vation group and a control group, 68 cases in each group. The observation group were treated with drug-separated moxibustion at Shenque (CV 8) and the control group with oral administration of Smecta. The mean diarrhea-stopping time, the negative conversion rate of Human Rotavirus antigen in stool after treatment for 72 h, and the markedly-effective rate and the total effective rate were observed after treatment for 6 days in the twO groups.

RESULTS

The markedly-effective rate and the total effective rate were 79.4% and 94.1% in the observation group and 35.3% and 75.0% in the control group, respectively, with very significantly or significantly difference between the two groups (P < 0.01 or P < 0.05); the mean diarrhea-stopping time in the observation group was shorter than that in the control group (P < 0.01); the negative conversion rate of Human Rotavirus antigen in stool after treatment for 72 h was 88.2%0 in the observation group and 69.1% in the control group with a very significantly difference between the two groups (P < 0.01).

CONCLUSION

Drug-separated moxibustion at Shenque (CV 8) has a significant therapeutic effect on infantile autumn diarrhea, helps negative conversion of Human Rotavirus antigen in stool and shortens duration of disease.