Colin F. Macdougall

How dangerous is food allergy in childhood? The incidence of severe and fatal allergic reactions across the UK and Ireland

Aims: To discover the incidence of fatal and severe allergic reactions to food in a large population of children. Methods: A retrospective search for fatalities in children 0–15 years from 1990 to February 1998, primarily of death certification at offices of national statistics. A prospective survey of fatal and severe reactions from March 1998 to February 2000, primarily through the British Paediatric Surveillance Unit. Main outcome measures were deaths and severe reactions. A case was deemed severe if one or more of the following criteria was met: cardiorespiratory arrest; need for inotropic support; fluid bolus >20 ml/kg; more than one dose of epinephrine; more than one dose of nebulised bronchodilator. A case was deemed near fatal if intubation was necessary. Results: The UK under 16 population is 13 million. Over the past 10 years, eight children died (incidence of 0.006 deaths per 100 000 children 0–15 years per year). Milk caused four of the deaths. No child under 13 died from peanut allergy. Two children died despite receiving early epinephrine before admission to hospital; one child with a mild food allergic reaction died from epinephrine overdose. Over the past two years, there were six near fatal reactions (none caused by peanut) and 49 severe ones (10 caused by peanut), yielding incidences of 0.02 and 0.19 per 100 000 children 0–15 years per year respectively. Coexisting asthma is more strongly associated with a severe reaction than the severity of previous reactions. Conclusions: If 5% of the child population have food allergy, the risk that a food allergic child will die from a food allergic reaction is about 1 in 800 000 per year. The food allergic child with asthma may be at higher risk. Prescribing an epinephrine autoinjector requires a careful balance of advantages and disadvantages.

The effectiveness of case-based learning in health professional education. A BEME systematic review: BEME Guide No. 23.

Background: Case-based learning (CBL) is a long established pedagogical method, which is defined in a number of ways depending on the discipline and type of ‘case’ employed. In health professional education, learning activities are commonly based on patient cases. Basic, social and clinical sciences are studied in relation to the case, are integrated with clinical presentations and conditions (including health and ill-health) and student learning is, therefore, associated with real-life situations. Although many claims are made for CBL as an effective learning and teaching method, very little evidence is quoted or generated to support these claims. We frame this review from the perspective of CBL as a type of inquiry-based learning. Aim: To explore, analyse and synthesise the evidence relating to the effectiveness of CBL as a means of achieving defined learning outcomes in health professional prequalification training programmes. Method: Selection criteria: We focused the review on CBL for prequalification health professional programmes including medicine, dentistry, veterinary science, nursing and midwifery, social care and the allied health professions (physiotherapy, occupational therapy, etc.). Papers were required to have outcome data on effectiveness. Search strategies: The search covered the period from 1965 to week 4 September 2010 and the following databases: ASSIA, CINAHL, EMBASE, Education Research, Medline and Web of Knowledge (WoK). Two members of the topic review group (TRG) independently reviewed the 173 abstracts retrieved from Medline and compared findings. As there was good agreement on inclusion, one went onto review the WoK and ASSIA EndNote databases and the other the Embase, CINAHL and Education Research databases to decide on papers to submit for coding. Coding and data analysis: The TRG modified the standard best evidence medical education coding sheet to fit our research questions and assessed each paper for quality. After a preliminary reliability exercise, each full paper was read and graded by one reviewer with the papers scoring 3–5 (of 5) for strength of findings being read by a second reviewer. A summary of each completed coding form was entered into an Excel spread sheet. The type of data in the papers was not amenable to traditional meta-analysis because of the variability in interventions, information given, student numbers (and lack of) and timings. We, therefore, adopted a narrative synthesis method to compare, contrast, synthesise and interpret the data, working within a framework of inquiry-based learning. Results: The final number of coded papers for inclusion was 104. The TRG agreed that 23 papers would be classified as of higher quality and significance (22%). There was a wide diversity in the type, timing, number and length of exposure to cases and how cases were defined. Medicine was the most commonly included profession. Numbers of students taking part in CBL varied from below 50 to over 1000. The shortest interventions were two hours, and one case, whereas the longest was CBL through a whole year. Group sizes ranged from students working alone to over 30, with the majority between 2 and 15 students per group. The majority of studies involved single cohorts of students (61%), with 29% comparing multiple groups, 8% involving different year groups and 2% with historical controls. The outcomes evaluation was either carried out postintervention only (78 papers; 75%), preintervention and postintervention (23 papers; 22%) or during and postintervention (3 papers; <3%). Our analysis provided the basis for discussion of definitions of CBL, methods used and advocated, topics and learning outcomes and whether CBL is effective based on the evaluation data. Conclusion: Overwhelmingly, students enjoy CBL and think that it enhances their learning. The empirical data taken as a whole are inconclusive as to the effects on learning compared with other types of activity. Teachers enjoy CBL, partly because it engages, and is perceived to motivate, students. CBL seems to foster learning in small groups though whether this is the case delivery or the group learning effect is unclear.

Severe food‐allergic reactions in children across the UK and Ireland, 1998–2000

Aim: Medical and lay concerns about food allergy are increasing. Whilst food allergy may be becoming more common, fatal reactions to food in childhood are very rare and their rate is not changing. We sought to establish how common severe reactions are. Methods: Prospective survey, 1998 to 2000, of hospital admissions for food‐allergic reactions—conducted primarily through the British Paediatric Surveillance Unit, covering the 13 million children in the United Kingdom and Ireland. Results: 229 cases reported by 176 physicians in 133 departments, yielding a rate of 0.89 hospital admissions per 100 000 children per year. Sixty‐five per cent were male, 41% were under 4 y and 60% started at home. Main allergens were peanut (21%), tree nuts (16%), cows milk (10%) and egg (7%). Main symptoms were facial swelling (76%), urticaria (69%), respiratory (66%), shock (13%), gastrointestinal (4%). Fifty‐eight cases were severe. Three were fatal, six near fatal, and 8 of these 9 had asthma with wheeze being the life‐threatening symptom. Three near‐fatal cases received excess intravenous epinephrine. None of the non‐fatal reactions resulted in mental or physical impairment. Seven of 171 non‐severe and 6/58 severe cases might have had a worse outcome if epinephrine auto‐injectors had been unavailable. Six of the severe cases might have benefited if auto‐injectors had been more widely prescribed.

Comparing the performance of graduate-entry and school-leaver medical students

Medical Education 2010: 44: 699–705

The concerns of school staff in caring for children with diabetes in primary school

Boden S, Lloyd CE, Gosden C, Macdougall C, Brown N, Matyka K. The concerns of school staff in caring for children with diabetes in primary school.

Maximising learning opportunities in handover

Handing over responsibility for patients has always been part of medical practice. Definitions emphasise transfer of responsibility to ensure patient safety and the available literature tends to follow this line (see box 1). Handover is much more than this, however. It is a key event where teams meet, have the opportunity to communicate, support each other and learn. This paper considers different ways of maximising learning opportunities in handover, with particular emphasis on the strengths and challenges of the paediatric environment. Alongside review of the best available evidence, many of the ideas discussed were generated from working with a group of 65 experienced paediatricians with particular experience and interest in medical education as part of the Royal College of Paediatrics and Child Health Paediatric Educators Programme. Formal handover has increased in importance and been embedded in practice with the transition from “on-calls” to “full-shift” rotas in an effort to comply with the European Working Time Directive1 in the United Kingdom (UK). Departments responsible for acute patient care have had to incorporate two or three handover sessions into every day to ensure patient problems and management plans are appreciated by the incoming medical team. #### Box 1 Definition of “handover” Handover is “the transfer of professional responsibility and accountability for some or all aspects of care for a patient, or group of patients, to another person or professional group on a temporary or permanent basis” (The National Patient Safety Agency2). Surveys have been conducted to look at handover practices2–4 and to consider how changes, perceived to improve practice, can be implemented. It is widely acknowledged that the primary aim of handover is to ensure effective continuity of care for patients, and a number of guidelines and frameworks have been published to promote this.5–10 The focus is mainly on …

Design, validation and dissemination of an undergraduate assessment tool using SimMan in simulated medical emergencies

Background: Increasingly, medical students are being taught acute medicine using whole-body simulator manikins. Aim: We aimed to design, validate and make widely available two simple assessment tools to be used with Laerdal SimMan® for final year students. Methods: We designed two scenarios with criterion-based checklists focused on assessment and management of two medical emergencies. Members of faculty critiqued the assessments for face validity and checklists revised. We assessed three groups of different experience levels: Foundation Year 2 doctors, third and final year medical students. Differences between groups were analysed, and internal consistency and interrater reliability calculated. A generalisability analysis was conducted using scenario and rater as facets in design. Results: A maximum of two items were removed from either checklist following the initial survey. Significantly different scores for three groups of experience for both scenarios were reported (p < 0.001). Interrater reliability was excellent (r > 0.90). Internal consistency was poor (α < 0.5). Generalizability study results suggest that four cases would provide reliable discrimination between final year students. Conclusions: These assessments proved easy to administer and we have gone some way to demonstrating construct validity and reliability. We have made the material available on a simulator website to enable others to reproduce these assessments.

Warwick Medical School : A four dimensional curriculum

Abstract Medical curricula vary hugely across the world. Notions of horizontal and vertical integration and spiral curricula are present in many modern curricula although true integration happens to a varying degree. By seeing the development of a curriculum as fundamentally about integration, rather than as a process of seeking to integrate separate elements, we have developed a program that prepares students well for the complexities and rate of change of practice. The risks inherent in bringing forward the point at which learners need to deal with such substantive and fundamental complexity produces challenges. Such challenges are ones that our students have shown they can not only deal with, they are often better equipped than faculty to provide solutions for themselves, their peers and those who follow them. We present the three dimensions of integration in the Warwick Medical School curriculum and note the fourth dimension provided by our students, being student led teaching and support far beyond what is normally found in medical courses.

Evaluation - the educational context.

Evaluation comes in many shapes and sizes. It can be as simple and as grounded in day to day work as a clinical teacher reflecting on a lost teaching opportunity and wondering how to do it better next time or as complex, top down and politically charged as a major government led evaluation of use of teaching funds with the subtext of re-allocating them. Despite these multiple spectra of scale, perceived ownership, financial and political implications, the underlying principles of evaluation are remarkably consistent. To evaluate well, it needs to be clear who is evaluating what and why. From this will come notions of how it needs to be done to ensure the evaluation is meaningful and useful. This paper seeks to illustrate what evaluation is, why it matters, where to start if you want to do it and how to deal with evaluation that is external and imposed.

Keeping it simple – audio taping in consultation performance assessment

The assessment of communication performance is increasingly recognised as central in acute hospital specialities. We wished to measure this in Paediatric Senior House Of®cers (SHOs) using the Maastricht history-taking and advice checklist (MAAS Global). Video techniques are well-described but their use in the secondary care setting poses challenges not faced by research conducted in general practice and psychiatry. They work best with well-sited equipment in an appropriately sized and shaped room. Paediatric SHOs mostly communicate on wards and during emergency consultations. In the study hospital, Accident and Emergency (A & E) patients and General Practice referrals are seen in four small rooms and a curtained bay. All are in continuous use by multiple specialities, two are too small to easily site a movable camera and rooms cannot be allocated to a given doctor. Video observation of an SHO would have required static and expensive equipment in all rooms and explanation to and by approximately 60 staff of other specialities using those rooms. By comparison, audio equipment is cheap, easily moved, is unobtrusive and can be set up instantly without the need to check inclusion in the picture. To assess what effect audio taping would have on test scores, we video taped 15 consultations and audio taped 80 consultations. The video taped consultations were scored against the 12 relevant domains of MAAS-Global twice, by one scorer (CM), using the sound alone on one occasion and both sound and vision on the other. The two scorings were done three months apart and whether each consultation was scored ®rst by sound or by both sound and vision was randomized. Informed consent was undertaken and the number withholding consent recorded.