An e-learning pediatric cardiology curriculum for Pediatric Postgraduate trainees in Rwanda: implementation and evaluation

BACKGROUND

Access to pediatric sub-specialty training is a critical unmet need in many resource-limited settings. In Rwanda, only two pediatric cardiologists are responsible for the country's clinical care of a population of 12 million, along with the medical education of all pediatric trainees. To strengthen physician training opportunities, we developed an e-learning curriculum in pediatric cardiology. This curriculum aimed to "flip the classroom", allowing residents to learn key pediatric cardiology concepts digitally before an in-person session with the specialist, thus efficiently utilizing the specialist for additional case based and bedside teaching.

METHODS

We surveyed Rwandan and US faculty and residents using a modified Delphi approach to identify key topics in pediatric cardiology. Lead authors from Rwanda and the USA collaborated with OPENPediatrics™, a free digital knowledge-sharing platform, to produce ten core topics presented in structured videos spanning 4.5 h. A mixed methods evaluation was completed with Rwandan pediatric residents, including surveys assessing knowledge, utilization, and satisfaction. Qualitative analysis of structured interviews was conducted using NVivo.

RESULTS

Among the 43 residents who participated in the OPENPediatrics™ cardiology curriculum, 33 (77%) completed the curriculum assessment. Residents reported using the curriculum for a median of 8 h. Thirty-eight (88%) reported viewing the curriculum on their personal or hospital computer via pre-downloaded materials on a USB flash drive, with another seven (16%) reporting viewing it online. Twenty-seven residents viewed the course during core lecture time (63%). Commonly reported barriers to utilization included lack of time (70%), access to internet (40%) and language (24%). Scores on knowledge assessment improved from 66.2% to 76.7% upon completion of the curriculum (p < 0.001) across all levels of training, with most significant improvement in scores for PGY-1 and PGY-2 residents. Residents reported high satisfaction with the visuals, engaging presentation, and organization of the curriculum. Residents opined the need for expanded training material in cardiac electrocardiogram and echocardiogram and requested for slower narration by foreign presenters.

CONCLUSION

Video-based e-learning via OPENPediatrics™ in a resource-limited setting was effective in improving resident's knowledge in pediatric cardiology with high levels of utilization and satisfaction. Expanding access to digital curriculums for other pediatric sub-specialties may be both an effective and efficient strategy for improving training in settings with limited access to subspecialist faculty.

Management of pediatric chest pain using a standardized assessment and management plan

OBJECTIVES

Chest pain is a common reason for referral to pediatric cardiologists and often leads to an extensive cardiac evaluation. The objective of this study is to describe current management practices in the assessment of pediatric chest pain and to determine whether a standardized care approach could reduce unnecessary testing.

PATIENTS AND METHODS

We reviewed all patients, aged 7 to 21 years, presenting to our outpatient pediatric cardiology division in 2009 for evaluation of chest pain. Demographics, clinical characteristics, patient outcomes, and resource use were analyzed.

RESULTS

Testing included electrocardiography (ECG) in all 406 patients, echocardiography in 175 (43%), exercise stress testing in 114 (28%), event monitoring in 40 (10%), and Holter monitoring in 30 (7%). A total of 44 (11%) patients had a clinically significant medical or family history, an abnormal cardiac examination, and/or an abnormal ECG. Exertional chest pain was present in 150 (37%) patients. In the entire cohort, a cardiac etiology for chest pain was found in only 5 of 406 (1.2%) patients. Two patients had pericarditits, and 3 had arrhythmias. We developed an algorithm using pertinent history, physical examination, and ECG findings to suggest when additional testing is indicated. Applying the algorithm to this cohort could lead to an ∼20% reduction in echocardiogram and outpatient rhythm monitor use and elimination of exercise stress testing while still capturing all cardiac diagnoses.

CONCLUSIONS

Evaluation of pediatric chest pain is often extensive and rarely yields a cardiac etiology. Practice variation and unnecessary resource use remain concerns. Targeted testing can reduce resource use and lead to more cost-effective care.

The effect of heparin on the haemodynamic and structural response in the rat to acute and chronic hypoxia

In the mouse, heparin administered intermittently, has been shown to reduce the right ventricular hypertrophy (RVH) caused by hypoxia. We have investigated in the rat the effect of heparin on the haemodynamic and pulmonary vascular structural remodelling produced by hypoxia, with special reference to the new muscularization of peripheral arteries. Heparin at one of two doses (30 and 50 u/kg/h) was administered by continuous intravenous infusion from a miniosmotic pump to rats during 10 days exposure to hypobaric hypoxia and its effect examined on mean pulmonary artery pressure (PPa), RVH and, using morphometric techniques, vascular structural remodelling. Hypoxia produced the haemodynamic and structural changes previously described in this model. Heparin had no significant effect on PPa; a slight reduction in RVH was seen in the high-dose heparin group. After heparin, the narrowing of the axial pulmonary artery lumen caused by hypoxia was less: heparin reduced the proportion of arteries that became muscularized, particularly at alveolar duct level where the pericyte is the precursor smooth muscle cell. Heparin did not diminish the increase in medial thickness or reduction in external diameter of muscular arteries. Some rats, after chronic hypoxia, did not respond to an acute hypoxic challenge yet were no different from 'responders' in other haemodynamic and structural features. Including all rats, the mean acute pressor response to hypoxia was unaffected by heparin: taking only responder rats, a trend was apparent that heparin reduced the rise in PPa on acute hypoxic challenge.