Lost in translation: a national cross-sectional study on medical interpreter use by pediatric residents

BACKGROUND

Lack of communication in a family's preferred language is inequitable and results in inferior care. Pediatric residents provide care to many families with non-English or French language preferences (NEFLP). There is no data available about how Canadian pediatric residents use interpreters, making it difficult to develop targeted interventions to improve patient experience.

OBJECTIVES

Our purpose was to assess translation services in pediatric training centers and evaluate resident perception of their clinical skills when working with NEFLP patients and families. This survey represents the first collection of data from Canadian pediatric residents about interpreter services.

METHODS

Eligible participants included all pediatric residents enrolled in an accredited Canadian pediatric training program. An anonymous survey was developed in REDCap© and distributed via email to all pediatric residents across Canada. Descriptive statistics were performed in STATA v15.1.

RESULTS

122 residents responded. Interpreter services were widely available but underused in a variety of clinical situations. Most (85%) residents felt they provided better care to patients who shared their primary language (English or French), compared with families who preferred other languages-even when an interpreter was present. This finding was consistent across four self-assessed clinical skills.

CONCLUSIONS

Residents are more confident in their clinical and communication skills when working with families who share their primary language. Our findings suggest that residents lack the training and confidence to provide equal care to families with varying language preferences. Pediatric training programs should develop curriculum content that targets safe and effective interpreter use while reviewing non-spoken aspects of cultural awareness and safety.

Conservative and Surgical Modalities in the Management of Pediatric Parapneumonic Effusion and Empyema: A Living Systematic Review and Network Meta-Analysis

BACKGROUND

The optimal treatment for community-acquired childhood pneumonia complicated by empyema remains unclear.

RESEARCH QUESTION

In children with parapneumonic effusion or empyema, do hospital length of stay and other key clinical outcomes differ according to the treatment modality used?

STUDY DESIGN AND METHODS

A living systematic review of randomized controlled trials (RCTs) was conducted by searching the Cochrane Central Register of Controlled Trials, Embase, Latin American and Caribbean Health Sciences Literature, Ovid MEDLINE, and Web of Science Core Collection databases. Eligible RCTs included patients aged < 18 years and compared two of the following treatment modalities: antibiotics alone, chest tube insertion with or without fibrinolytics, video-assisted thoracoscopic surgery (VATS), and decortication via thoracotomy. A network meta-analysis was performed to evaluate treatment effects on hospital length of stay (LOS), the primary outcome.

RESULTS

Eleven trials including a total of 590 patients were selected for the network meta-analysis. Compared with a chest tube alone, a chest tube with fibrinolytics, thoracotomy, and VATS were all associated with shorter LOS, with a mean difference of 5.05 days (95% CI, 2.46-7.64), 6.33 days (95% CI, 3.17-9.50), and 5.86 days (95% CI, 3.38-8.35), respectively. No substantial differences in LOS were observed between the latter three interventions. None of the 11 RCTs compared antibiotics alone vs other types of treatment. Most trials reported peri-procedural complications and the need for reintervention, but the descriptions differed significantly between trials, preventing meta-analysis. In trials reporting health care-associated costs, fibrinolytics had cost advantages compared with VATS. Short- and long-term morbidity and mortality were very low, regardless of the treatment modality.

INTERPRETATION

The results of this network meta-analysis showed that a chest tube alone was associated with a longer LOS compared with other treatment modalities. The lower cost associated with a chest tube plus fibrinolytics warrants consideration when choosing between treatment options, given similar LOS and clinical outcomes compared with the other modalities.

Short duration of parenteral antibiotics in infants with urinary tract infections

Objectives

Current guidelines by the Canadian Paediatric Society on treating urinary tract infections (UTIs) exclude infants ≤ 60 days old. There is considerable practice variability in this age group, especially around the optimal duration of parenteral antibiotics. The study aimed to assess local practice patterns, and the safety of a short course (≤3 days) of parenteral antibiotics in young infants.

Methods

In this retrospective cohort study, 95 infants (≤60 days) with confirmed UTIs were identified at British Columbia Children's Hospital. Patients receiving short (≤3 days) and long (>3 days) duration of parenteral antibiotics were compared. Outcomes of interest included urinary tract infection recurrence within 30 days, hospital length of stay (LOS), representation, and readmission.

Results

Twenty infants (21%) received a short course of parenteral antibiotics. These infants were older (median 47 days versus 28 days) and non-bacteremic. Urinary tract infection recurrence was identified in 8 patients (8%), of which 7 were treated with a long duration (P = 1.0). Patients treated with a short duration had a significantly shorter LOS, with a mean difference of 4.21 days [95% CI: 3.37 to 5.05] (P < 0.001). All five (5%) bacteremic patients were treated exclusively with parenteral antibiotics.

Conclusions

In a Canadian setting, a short course of parenteral antibiotics is safe in young, non-bacteremic infants with UTIs. Despite substantial evidence, local practice patterns suggest a tendency towards prescription of long courses, providing an opportunity for quality improvement.

96 Impact and Feasibility of a Pediatric Social Determinants of Health Questionnaire: A Pilot Mixed-Methods Study

Background

Social determinants of health (SDoH)—which are factors such as socioeconomic status (SES), access to transportation, food and housing security, disability and social supports—have been shown to influence up to 50% of health in patients. The project team developed a SDoH Questionnaire which evolved into what is now referred to as BEARS (Barriers to Care, Economic Factors, Adversity, Resiliency, Social Capital). Part of the BEARS Questionnaire includes an optional section for inquiring about Adverse Childhood Experiences (ACEs).

Objectives

The primary purpose of this study was to evaluate the impact and feasibility of the BEARS Questionnaire. Additional objectives were to assess the utility and functionality of the BEARS Questionnaire as a social history-taking tool, including the cumulative ACEs questions, and obtain suggestions for improvement of the tool.

Design/Methods

This was a mixed methods pilot study that consisted of quantitative surveys and qualitative structured interviews with clinicians who had experience using the BEARS Questionnaire. Descriptive statistics were performed on all survey results. Thematic analysis was performed on clinician interviews with recurrent themes being identified through iterative analysis and tagged quotations.

Results

15 clinicians completed the quantitative survey and five took part in a qualitative interview. Study participants included surgeons, pediatricians, speech language pathologists, social workers and nurse clinicians. The BEARS Questionnaire changed clinician practice by increasing the frequency and breadth of social screening in their patients and optimizing care to fit their patients’ social context. Participants described the BEARS as an effective screening tool for SDoH and ACEs that was feasible to implement into their clinic workflow.

Three themes emerged from our interviews: (1) Thorough social history taking highlights family resiliency and improves clinician-patient rapport, (2) Screening for ACEs is acceptable and feasible in a safe clinical environment, and (3) Social screening is feasible in a busy clinical environment and there is room for improvement.

Conclusion

This study highlights the importance of social screening in pediatric patients and their families, and how using a social screening tool allows providers to tailor care for a patients’ social context. The BEARS Questionnaire is feasible to implement within the context of a busy clinic. Finally, despite being a sensitive topic, an ACEs questionnaire can be incorporated when done in a trauma-informed way, and in the context of a longitudinal therapeutic relationship.

Treatment of UTIs in Infants <2 Months: A Living Systematic Review

CONTEXT

Urinary tract infections (UTIs) are the most common bacterial infections in infants <2 months of age. However, there are no clear guidelines on the appropriate duration of antibiotics in this age group.

OBJECTIVE

In this living systematic review, we compared different durations of parenteral antibiotics (≤3 vs >3 days) in neonates and young infants (<2 months) with UTIs. The secondary objective was to compare different durations of total antibiotic courses (≤10 vs >10 days).

DATA SOURCES

MEDLINE, Embase, Cochrane Central Register of Controlled Trials, Web of Science, Literatura Latino-Americana e do Caribe em Ciências da Saúde, Google Scholar, and gray literature, up to March 2, 2021.

STUDY SELECTION

Citations were screened in triplicate by using a crowdsourcing methodology, to identify randomized controlled trials and observational studies.

DATA EXTRACTION

Data were extracted by 2 crowd members and verified by an expert investigator. Outcomes were pooled via random-effects models.

RESULTS

A total of 10 334 citations were screened, and 12 eligible studies were identified. A total of 59 of 3480 (1.7% [95% confidence interval (CI): 1.3% to 2.2%]) infants had a UTI recurrence within 30 days after short parenteral treatment (≤3 days), and 47 of 1971 (2.4% [95% CI: 1.8% to 3.2%]) after longer courses. The pooled adjusted odds ratio for UTI recurrence with a short versus long duration of parenteral antibiotics was 1.02 (95% CI: 0.64 to 1.61; P = .95; n = 5451). A total of 5 studies assessed the risk of recurrence on the basis of the total duration of antibiotics (≤10 vs >10 days) with no significant differences (pooled odds ratio: 1.29 [95% CI: 0.45 to 3.66; P = .63; n = 491).

CONCLUSIONS

On the basis of retrospective studies and Grading of Recommendations, Assessment, Development, and Evaluation level low evidence, short and long duration of parenteral antibiotics were associated with a similar risk of UTI recurrence in infants <2 months.

O-238 Preterm birth after recurrent pregnancy loss: A systematic review and meta-analysis

Study question

What is the impact of recurrent pregnancy loss on the risk of preterm birth?

Summary answer

Women with RPL were found to be at increased odds of having preterm deliveries (&lt;37 weeks gestation) in their subsequent live pregnancies.

What is known already

Recurrent pregnancy loss (RPL) occurs in up to 5% of all women with miscarriages. The emotional, physical, and financial burden associated with RPL is unequivocal, and over the years, much research has gone into the management of RPL. However, relatively little is known about the perinatal outcomes following RPL. Past research in the area reports conflicting data on the association between RPL and preterm birth (PTB) in a subsequent pregnancy.

Study design, size, duration

A systematic search was performed across thePubMed, EMBASE and Google Scholar databases for relevant studies published up until October 2020. Observational cohort and case-control studies comparing the risk of preterm birth (PTB) among women with and without a history of RPL were included. Effect estimates were pooled using a DerSimonian and Laird random-effects meta-analysis model. Study appraisal was performed using the Newcastle-Ottawa scale.

Participants/materials, setting, methods

We included studies where the study population consisted of women with a history of RPL (defined as 2 or more pregnancy losses), where the comparator group consisted of women without a history of RPL, and where the outcomes assessed included PTB (defined as birth prior to 37 completed weeks gestation). Two reviewers independently extracted data in duplicate. Publication date, population, exposure and outcome data were extracted.

Main results and the role of chance

A total of 12 retrospective observational studies met inclusion criteria, and were included in the systematic review and meta-analysis (N = 37,046 women with a history of RPL). Incidence of PTB among the RPL groups ranged from 5.8% to 19.6%, and from 1.5-14.0% in the non-RPL groups. A pooled OR of 1.59 with 95% CI 1.40-1.80 was observed in our random-effects meta-analysis with an I2 of 84%. Subgroup analyses were completed for the pooled risk of only 2 RPL (pooled odds ratio [OR] 1.35; 95% CI 1.08-1.69; I2=84.7%); ≥2 RPL (pooled OR 1.42; 95% CI 0.91-2.22; I2=68.9%); and ≥3 RPL (pooled OR 1.86; 95% CI 1.51-2.29; I2=79.5%).

Limitations, reasons for caution

Inconsistent adjustment for confounders and significant between-study heterogeneity were noted in this study.

Wider implications of the findings

Despite significant heterogeneity among studies, we found that women with a history of RPL had significantly higher odds of delivering preterm infants in their subsequent pregnancies.

Trial registration number

CRD 224763

Conservative and surgical modalities in the management of paediatric parapneumonic effusion and empyema: a protocol for a living systematic review and network meta-analysis

INTRODUCTION

Parapneumonic effusion and empyema are common complications of paediatric pneumonia. Acceptable treatment modalities for large parapneumonic effusions include antibiotics alone or in conjunction with surgical interventions. Clear guidelines on the best treatment approach are lacking and mostly based on evidence prior to widespread pneumococcal conjugate 13-valent vaccination (PCV-13).

METHODS AND ANALYSIS

A living systematic review and network meta-analysis will be performed comparing the five treatment modalities: (1) antibiotics alone; (2) chest tube drainage without fibrinolytics; (3) chest tube drainage with fibrinolytics; (4) video-assisted thoracoscopic surgery and (5) open thoracotomy. The review protocol is reported following the Preferred Reporting Items for Systematic Review and Meta-Analysis Protocols guidelines. Eligible studies are randomised controlled trials comparing any pair of interventions in paediatric patients with empyema or parapneumonic effusion. The following databases will be searched: Ovid MEDLINE, EMBASE, Cochrane Central Register of Controlled Trials (CENTRAL), Web of Science, LILACS and Google Scholar. Citation screening and data extraction will be completed using a validated crowdsourcing methodology using InsightScope. To assess the risk of bias, we will use the revised Cochrane risk of bias tool for randomised trials. The primary outcome of the study is the length of stay. Secondary outcomes are (1) periprocedural complications and (2) need for re-intervention. A frequentist network meta-analysis design will be implemented with a random-effects model comparing different interventions. In a subgroup analysis, studies and patients will be stratified by the size of pleural effusion and the date of trial (pre/post-PCV-13). Eligible citations and available results will be uploaded to an online database, hosted on Open Science Framework. The database will be updated at least every 4 months with any newly published research.

ETHICS AND DISSEMINATION

No ethics review is required for this study. Results will be published in a peer-reviewed journal. Data will be available as part of an online database summarising the evidence of this living systematic review.

PROSPERO REGISTRATION

Pending peer review.

ADDRESSING ADVERSE CHILDHOOD EXPERIENCES (ACES) BY COMBINING PUBLIC HEALTH, SOCIAL PEDIATRIC AND RICHER COMMUNITY BASED APPROACHES

BACKGROUND

The Canadian Social Pediatric Interest Group has developed emerging research partnerships over the past decade. In this multi-centre partnership, we characterize social paediatrics programs (SPPs) in three dimensions: 1) fostering health equity; 2) inter-professional integration, and 3) community embeddedness, all of which involve independently complex sets of interventions. The aim of the RICHER (responsive, interdisciplinary, community health, education and research) SPP is to provide timely access to prevention and intervention services for children and youth at higher risk due to multiple social determinants of health(SDoH) including adverse childhood experiences (ACEs) and material and social poverty.

OBJECTIVES

Our objectives are to 1) translate SPP knowledge and experience into policy and practice through formal literature reviews and mixed methods research, 2) further develop and integrate SPPs quality improvement(QI) and research, and 3) integrate trauma informed ACE research findings into primary care and paediatric practices in Canada.

DESIGN/METHODS

Following established realist synthesis methodology, built on earlier mixed methods research, a literature review was undertaken to identify key mechanisms linking context/environment to health outcomes. The study method included: (1) identifying the review question, (2) formulating the initial theory, (3) searching for primary studies, (4) selecting and appraising study quality, (5) extracting, analyzing and synthesizing relevant data, and (6) refining the theory. Using mixed methods approaches, the RICHER SPP research data was analyzed to identify outcomes, develop and update logic models. Health professional survey of paediatric specialists and surgeons has been developed to explore knowledge of ACEs and SDoH and how these impact practice.

RESULTS

Analyses of the literature for the realist synthesis resulted in semi-predictable patterns where outcomes could be linked to activities through mechanisms. Key mechanisms were 1) willingness to share power, 2) bridging trust and relationships 3) inter-professional knowledge support and 4) family/ community empowerment. Key features of RICHER SPPs included trust, equity and partnerships, leading to parental and community engagement, improved access to services and enriched environments. There was a measured ‘critical difference’ in vulnerability on the HELP Early Developmental Index (EDI) during the study period. An approach to integrating and evaluating ACEs in different SPP practice settings has been initiated through research and QI projects.

CONCLUSION

Our realist synthesis identified processes of care that were effective in improving health and developmental outcomes for children and youth with adverse social and material circumstances. ‘RICHER’ SPPs, distributed in neighbourhood spaces, link primary and specialist care for vulnerable children and youth, improve health and developmental outcomes and foster equitable access to health care and transition services. These approaches may be translated into other contexts to improve access for more socially vulnerable children and youth and better integrate our knowledge of ACES into paediatric and youth health practices.

Is There an App for That? Assessing the Quality and Content of Apps for Asthma Management Available In Canada

BACKGROUND: Asthma is the most common chronic respiratory disease in Canada, with highest prevalence in children 5-17 years of age. The use of effective apps for asthma management for children and adolescents may decrease the significant morbidity of this disease. A wide range of apps designed to assist in the home management of asthma are available online. However, there are no published data assessing the quality and content of asthma apps for children and families in Canada.

OBJECTIVES: To evaluate apps targeted at children or parents for the active management of asthma based on quality, accuracy of content and presence of advertising.

DESIGN/METHODS: The iOS and Google Play stores were searched using the key terms “asthma”, “reactive airways”, “puffer”, and “wheeze”. Apps that were available in English or French, were interactive, were targeted at children or their families, and addressed the medical management of asthma were included. Apps were examined using a detailed data collection tool to assess usability and content. Quality criteria was based on a published, validated tool. Content was evaluated based on the Canadian Thoracic Society asthma guidelines.

RESULTS: A total of 95 apps were screened, and 11 met the inclusion criteria. Average app quality score was 3.65 (range 2.63 – 4.38) out of 5. One app used 7 out of 7 CTS criteria in assessing asthma control, one used 6, six used 5, and three used 4. 10 out of 11 apps had the capacity to track symptoms, which was linked to level of asthma control based on CTS/CPS criteria. 8 out of 11 apps had the capacity to record medication doses in a journal format and provided daily medication reminders. 6 apps had the capacity to create and save a personalized asthma action plan. All apps used medications available in Canada. The most functional app based on these criteria was asthmamd, followed by AsthmaSense. One app was funded but a pharmaceutical company and had industry logo, but no significant brand bias. No other apps had specific industry advertising. None were specifically designed for use by children or adolescents.

CONCLUSION: 11 relatively high-quality apps are available for asthma management for Canadian families. Of these apps, the ones that best match quality, adherence to CTS guidelines, and lack of marketing/branding are asthmamd and AsthmaSense. There exists a gap to create apps that are specifically targeted at children and adolescents with high functionality for managing asthma.