Julie S. Byerley

Use of Antiemetic Agents in Acute Gastroenteritis : A Systematic Review and Meta-analysis

OBJECTIVE To perform a systematic review and meta-analysis to determine whether taking antiemetic drugs reduces vomiting and decreases the need for further intervention in children with gastroenteritis without causing significant adverse effects. DATA SOURCES Computerized databases, reference lists, and expert recommendations. STUDY SELECTION Prospective controlled trials evaluating medication use in children with vomiting from gastroenteritis. INTERVENTION Antiemetic drug therapy. MAIN OUTCOME MEASURES Emesis cessation, use of intravenous fluid for rehydration, hospital admission, return to care, and medication adverse effects. RESULTS The 11 articles that met the inclusion criteria evaluated various antiemetic agents: ondansetron (n = 6), domperidone (n = 2), trimethobenzamide (n = 2), pyrilamine-pentobarbital (n = 2), metoclopramide (n = 2), dexamethasone (n = 1), and promethazine (n = 1). Meta-analysis of 6 randomized, double-masked, placebo-controlled trials of ondansetron demonstrated decreased risk of further vomiting (5 studies; relative risk [RR], 0.45; 95% confidence interval [CI], 0.33-0.62; number needed to treat [NNT] = 5), reduced need for intravenous fluid (4 studies; RR, 0.41; 95% CI, 0.28-0.62; NNT = 5), and decreased risk of immediate hospital admission (5 studies; RR, 0.52; 95% CI, 0.27-0.95; NNT = 14). Diarrheal episodes increased in ondansetron-treated patients in 3 studies. Ondansetron use did not significantly affect return to care (5 studies; RR, 1.34; 95% CI, 0.77-2.35). CONCLUSIONS Ondansetron therapy decreases the risk of persistent vomiting, the use of intravenous fluid, and hospital admissions in children with vomiting due to gastroenteritis. Future treatment guidelines should incorporate ondansetron therapy for select children with gastroenteritis.

Professionalism Expectations Seen Through the Eyes of Resident Physicians and Patient Families

BACKGROUND: Resident physicians and patient families have not traditionally been involved in setting expectations for professional behavior by physicians. OBJECTIVE: To elicit and compare prioritized lists of attributes and behaviors of physician professionalism formulated by residents and patient families. METHODS/DESIGN: We used qualitative and quantitative methods to identify and compare prioritized perceptions of important attributes and behaviors of physician professionalism among residents and families of patients. We conducted 3 resident focus groups, 1 for residents in each resident-training year (postgraduate years 1, 2, and 3), and elicited attributes and behaviors the residents associated with physician professionalism by using free-listing and nominal-group techniques. Family perspectives of the attributes/behaviors of physician professionalism were elicited by using semistructured interviews of consecutive families with a child who was admitted to the hospital. All results were transcribed, and common themes were identified. RESULTS: Fifty-eight residents (78% of the total in the program) and 40 families participated. Similar themes arose from all 3 resident focus groups, which prioritized tactfulness, support of team members, respectfulness, good communication, and humanism. Residents also provided specific behavioral strategies to put these attributes into practice, such as avoiding jokes about patients and using patient names when addressing and discussing them. Patient families most frequently cited good communication, caring, knowledge, skill, honesty, and attitude. Communication and humanism were aspects consistently endorsed by both residents and patient families. CONCLUSIONS: There was important overlap in the attributes of professionalism generated and prioritized by resident physicians and patient families, although only residents identified ways that health care providers should interact with each other. This novel approach to identifying professionalism attributes provides opportunities for curriculum improvement.

Clinical approach to endogenous lipoid pneumonia

Endogenous lipoid pneumonia (ELP) is an underreported and underdiagnosed condition, with a high percentage of cases found on autopsy or late-stage disease (1). The etiology of ELP varies widely and includes obstructive, hematologic, oncologic, rheumatologic, infectious, idiopathic, inflammatory and immunologic diseases (Table 1) (2). Early diagnosis of ELP is critical because of serious and life-threatening complications of late-stage disease. Treatment and prognosis also vary based on underlying etiology of lipoid pneumonia and delayed diagnosis, which affect later treatment strategies. Unfortunately, there is no standard workup or established empiric treatment for ELP. We recently reported a case of ELP associated with non-specific interstitial pneumonitis and pulmonary alveolar proteinosis (PAP), which resulted in the death of the patient 10 months after ELP diagnosis (3). Based on an extensive review of the literature and experience with clinical cases of ELP, a standard diagnostic approach to ELP is proposed below in hopes of preventing a delay in diagnosis and treatment in future cases.

Use of serum electrolyte panels in gastroenteritis.

To the Editor .— Wathen et al1 studied the use of serum electrolyte panels (SEPs) for children needing intravenous fluid (IVF) for gastroenteritis. All children enrolled had obligatory SEPs drawn, and the results were presented to the attending physician. They then documented evaluation, management, and disposition plans. Because the SEPs changed decisions about clinical care and disposition, the authors concluded that SEPs are useful in all children receiving IVFs for gastroenteritis. We feel that the results are overstated because of a limited study design. Two of the study …

Pediatric emergencies in the family practice clinic

Case: A 9-month-old girl is brought by her mother because she is having difficulty breathing. Her mother states that the child is somewhat sleepy this morning after coughing all day yesterday and last night. She will no longer play or take a bottle and has not had a wet diaper this morning. You see a sleepy baby with obvious tachypnea, suprasternal and subcostal retractions, and nasal flaring. Difficulty breathing is a frequent complaint in the office setting with a broad differential and a wide range of severity. When addressing respiratory distress in children, it is important to define the location of pathology along the respiratory tract. The most common complaint involves congestion of the nose and upper respiratory tract. There is no effective means to address this complaint in babies other than mechanical suctioning of the upper airway after the application of saline drops. Reassurance and education is the role of the provider in this setting. When the pathology is found lower in the respiratory tract it can be more concerning.

Mentoring in the era of #MeToo

In the wake of the inspiring but incredibly upsetting #MeToo movement,1 I find myself concerned not only for the women who have already experienced sexual harassment, and certainly there are many, but also for those yet to come. Some will unfortunately experience the same pain, fear, humiliation, and stigma of sexual harassment as the stories being brought to light by the brave women who have been reporting their experiences today. In addition, I worry about the potential for gender-based neglect, an unintended backlash in response to this bright light. I worry about the women who will miss out on the mentorship of well-intentioned men who fear being accused of mistreatment. And I worry about the women who will be passed over because it’s simply “easier” for men to supervise men during this challenging time. And I worry that progress toward gender equity with leadership opportunities for women will regress. I have never had a female supervisor and, aside from many wonderful peer mentors, never had a close female mentor. I have, however, had the good fortune of generous men who have sponsored, inspired, and trained me along the way throughout my academic

Endogenous lipoid pneumonia preceding diagnosis of pulmonary alveolar proteinosis

Pulmonary alveolar proteinosis (PAP) is an under‐reported and under‐diagnosed condition, with a high percentage of cases found on autopsy or late stage disease. The etiology of PAP includes genetic, primary (anti‐granulocyte‐macrophage colony‐stimulating factor antibodies) and secondary (oncologic, rheumatologic, infectious, chemical and immunologic) causes. Here, we present the first reported pediatric case of endogenous lipoid pneumonia and non‐specific interstitial pneumonitis preceding the development of PAP.

Recruitment and Retention of Community Preceptors

We provide an analysis of the challenges and proposed solutions in recruiting and retaining community preceptors from the viewpoint of pediatric department chairs. BACKGROUND: Recruiting and retaining community-based pediatricians for teaching medical students has been explored through the lens of preceptors and educational leaders. The purpose of this study was to explore the perspective of pediatric department chairs, a key stakeholder group charged with maintaining teaching capacity among a faculty. METHODS: In 2015, members of the Association of Medical School Pediatric Department Chairs and Council on Medical Student Education in Pediatrics joint task force disseminated a 20-item survey to pediatric department chairs in the United States and Canada. Topics included demographics, incentives offered to community pediatricians, and the perceived value and feasibility of such incentives. Data were analyzed using descriptive statistics and χ2 to compare categorical variables. RESULTS: Pediatric department chairs from 92 of 145 (63% response rate) medical schools returned the survey. Sixty-seven percent reported difficulty recruiting or retaining preceptors, and 51% reported high-reliance on preceptors for the ambulatory portion of the pediatrics clerkship. Almost all (92%) cited competition from other programs for the services of community preceptors. The provision of incentives was correlated with perceived feasibility (R2 = 0.65) but not their perceived value (R2 = 0.12). Few (21%) chairs reported providing financial compensation to preceptors. The provision of compensation was not related to reliance but did vary significantly by geographical region (P < .001). CONCLUSIONS: Pediatric departments rely heavily on community-based pediatricians but face competition from internal and external training programs. The perspective of department chairs is valuable in weighing interventions to facilitate continued recruitment and retention of community preceptors.

A Simple Pyramid Model for Career Guidance

M edical educators frequently find themselves in conversations in which they are asked to offer career guidance. This may be part of a formal role as an assigned advisor, or in informal interactions with learners. Many medical schools have successfully integrated career advising for students in a multitude of ways, such as official mentoring programs, career services from nonmedical advisors, web-based resources, and career exploration courses. By comparison, the literature about career advising at the graduate medical education level is relatively limited, and provides little guidance for framing these advising conversations. Given the lack of formalized career counseling for residents, having a broad group of faculty skilled in these conversations is important. We have found career advising conversations with residents to be common, and a natural pattern has evolved. The model presented here uses a simple structure to facilitate these important conversations (FIGURE). It uses a pyramid model that is approached from the bottom up, narrowing a learner’s perspective toward more clarity regarding an appropriate career choice, or a next step in the career path.