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Student evaluation of an OSCE in paediatrics at the University of the West Indies, Jamaica

BackgroundThe Faculty of Medical Sciences, University of the West Indies first implemented the Objective Structured Clinical Examination (OSCE) in the final MB Examination in Medicine and Therapeutics during the 2000–2001 academic year. Simultaneously, the Child Health Department initiated faculty and student training, and instituted the OSCE as an assessment instrument during the Child Health (Paediatric) clerkship in year 5. The study set out to explore student acceptance of the OSCE as part of an evaluation of the Child Health clerkship.MethodsA self-administered questionnaire was completed by successive groups of students immediately after the OSCE at the end of each clerkship rotation. Main outcome measures were student perception of examination attributes, which included the quality of instructions and organisation, the quality of performance, authenticity and transparency of the process, and usefulness of the OSCE as an assessment instrument compared to other formats.ResultsThere was overwhelming acceptance of the OSCE in Child Health with respect to the comprehensiveness (90%), transparency (87%), fairness (70%) and authenticity of the required tasks (58–78%). However, students felt that it was a strong anxiety-producing experience. And concerns were expressed regarding the ambiguity of some questions and inadequacy of time for expected tasks.ConclusionStudent feedback was invaluable in influencing faculty teaching, curriculum direction and appreciation of student opinion. Further psychometric evaluation will strengthen the development of the OSCE.

Maternal antiretroviral use during pregnancy and infant congenital anomalies: the NISDI perinatal study.

Background:We evaluated the association between maternal antiretrovirals (ARVs) during pregnancy and infant congenital anomalies (CAs), utilizing data from the National Institute of Child Health and Human Development International Site Development Initiative Perinatal Study. Methods:The study population consisted of first singleton pregnancies on study, ≥20 weeks gestation, among women enrolled in NISDI from Argentina and Brazil who delivered between September 2002 and October 2007. CAs were defined as any major structural or chromosomal abnormality, or a cluster of 2 or more minor abnormalities, according to the conventions of the Antiretroviral Pregnancy Registry. CAs were identified from fetal ultrasound, study visit, and death reports. Prevalence rates [number of CAs per 100 live births (LBs)] were calculated for specific ARVs, classes of ARVs, and overall exposure to ARVs. Results:Of 1229 women enrolled, 995 pregnancy outcomes (974 LBs) met the inclusion criteria. Of these, 60 infants (59 LBs and 1 stillbirth) had at least 1 CA. The overall prevalence of CAs (per 100 LBs) was 6.2 [95% confidence interval (CI) 4.6 to 7.7]. The prevalence of CAs after first trimester ARVs (6.2; 95% CI 3.1 to 9.3) was similar to that after second (6.8; 95% CI 4.5 to 9.0) or third trimester (4.3; 95% CI 1.5 to 7.2) exposure. The rate of CAs identified within 7 days of delivery was 2.36 (95% CI 1.4 to 3.3). Conclusions:The prevalence of CAs after first trimester exposure to ARVs was similar to that after second or third trimester exposure. Continued surveillance for CAs among children exposed to ARVs during gestation is needed.

Kawasaki syndrome in Jamaica.

Objective. To determine the epidemiology, management and outcome of Kawasaki syndrome in patients presenting to the major referral centers in Jamaica (population, 2.5 million) from May, 1986, through June, 1998. Design and methods. Retrospective review of all cases of Kawasaki syndrome in major referral centers island wide. American Heart Association diagnostic criteria were used in case definition. Demographic, clinical diagnostic and laboratory data, management and outcome findings were analyzed. Results. Of 98 probable cases 57 were diagnosed with definite Kawasaki syndrome. The average annual incidence was 2.7 per 100 000 children in the 0‐ to 5‐year age group, in a predominantly black population. Eighty‐one percent of cases were from the Kingston Metropolitan area (population, 800 000). Children in the first 3 years of life were represented by 67% of cases, with a mean age of presentation of 32 months (range, 5 to 120 months). There was a male preponderance (M:F ratio, 1.71:1). The mean time between onset of illness and diagnosis was 9.1 days (sd 3.9 days). The most common presenting clinical features included fever, anorexia, vomiting, conjunctivitis, exanthema and oropharyngeal and peripheral extremity changes (>45% of patients). Only 7 children received treatment with intravenous gamma‐globulin. Overall 38.8% of patients had cardiovascular changes and 28% had coronary artery abnormalities. Girls (8 of 21, 38.1%) were significantly more likely to have coronary changes than boys (8 of 36, 28.5%) {P < 0.05}. Two (3.5%) patients experienced a recurrence. Conclusion. There is a tendency for late recognition and, hence, failure of treatment of Kawasaki syndrome in Jamaica. Greater awareness of the condition needs to be implemented. The finding of female children with an increased occurrence of coronary abnormalities warrants further investigation.

Student self-assessment in a paediatric objective structured clinical examination

OBJECTIVE The objective structured clinical examination (OSCE) has been recognized not only as a useful assessment tool but also as a valuable method of promoting student learning. Student self-assessment is also seen as a means of helping students recognize their strengths and weaknesses, understand the relevance of core learning objectives and to take more responsibility for each stage of their work The authors sought to evaluate the accuracy of medical student self-assessment of their performance in the paediatric clerkship OSCE and thus obtain preliminary data for use in programme strengthening. DESIGN AND METHODS A self-administered questionnaire was completed by successive groups of students immediately after the OSCE at the end of each clerkship rotation. Students assessed their performance at each station, using a performance rating scale. Performance data were summarized using descriptive and non-parametric tests. Basic statistical analysis of the Likert items was conducted by calculatingfrequencies, means and standard deviations. Regression analysis was used to correlate self-reported rating and actual performance in each station. A p value of < 0.05 was considered significant. Eighty-one students (92%) completed the questionnaire. RESULTS Fifty-eight (72%) of the students achieved greater than minimum competence in their overall scores. Significant positive correlation (p < 0.05) between student self-rating and actual score was noted- among the following stations: technical skills, cardiovascular examination, assessment of dysmorphism, dermatology, communication and photographic interpretation stations. Students overestimated their performance in the gastrointestinal examination, radiological and arterial blood gas interpretation. Students underestimated their performance in the following: respiratory system, examination of the head, developmental and nutritional assessment. CONCLUSIONS The findings highlight the perceived strengths and weaknesses in clinical competence and self-assessment skills and provide direction for programme training needs.

Mode of delivery and neonatal respiratory morbidity among HIV-exposed newborns in Latin America and the Caribbean: NISDI Perinatal-LILAC Studies.

To evaluate respiratory morbidity (RM) in HIV‐exposed newborns according to mode of delivery.

Undervaccination of perinatally HIV-infected and HIV-exposed uninfected children in Latin America and the Caribbean.

Background: Perinatally HIV-infected (PHIV) children may be at risk of undervaccination. Vaccination coverage rates among PHIV and HIV-exposed uninfected (HEU) children in Latin America and the Caribbean were compared. Methods: All PHIV and HEU children born from 2002 to 2007 who were enrolled in a multisite observational study conducted in Latin America and the Caribbean were included in this analysis. Children were classified as up to date if they had received the recommended number of doses of each vaccine at the appropriate intervals by 12 and 24 months of age. Fisher’s exact test was used to analyze the data. Covariates potentially associated with a child’s HIV status were considered in multivariable logistic regression modeling. Results: Of 1156 eligible children, 768 (66.4%) were HEU and 388 (33.6%) were PHIV. HEU children were significantly (P < 0.01) more likely to be up to date by 12 and 24 months of age for all vaccines examined. Statistically significant differences persisted when the analyses were limited to children enrolled before 12 months of age. Controlling for birth weight, sex, primary caregiver education and any use of tobacco, alcohol or illegal drugs during pregnancy did not contribute significantly to the logistic regression models. Conclusions: PHIV children were significantly less likely than HEU children to be up to date for their childhood vaccinations at 12 and 24 months of age, even when limited to children enrolled before 12 months of age. Strategies to increase vaccination rates in PHIV are needed.

Hepatitis B-associated nephrotic syndrome in Jamaican children

Abstract Between December 1984 and November 1996, 171 children under 12 years old presented to the University Hospital of the West Indies with nephrotic syndrome. Hepatitis B surface antigen (HBsAg) was found in ten (6%) of these children, eight of whom had membranous nephropathy (MN), and one each had mesangial proliferative glomerulonephritis (MesN) and minimal change nephrotic syndrome (MCNS). Only those children with MesN and MCNS were steroid-sensitive. The HBsAg-positive status was identified incidentally on screening. At a mean follow-up of 34 months, seven of ten children had experienced complete or partial remission and three had persistent nephrotic syndrome, although none was in renal failure. Six of the ten had biochemical hepatitis. All the children were still HBsAg-positive. Hepatitis B virus (HBV) is a factor contributory to nephrotic syndrome in Jamaican children. As diagnostic clinical markers for HBV-associated nephropathy are usually absent, all children presenting with nephrotic syndrome should be screened for HBsAg. A policy should be implemented in Jamaica for screening pregnant women and at-risk groups for HBsAg, as well as for immunising susceptible neonates, in order to reduce the incidence of HBV-associated pathology.

Family Relationships and Sexual Orientation Disclosure to Family by Gay and Bisexual Men in Jamaica

ABSTRACT Gay and bisexual men in Jamaica encounter stigma and discrimination due to criminalization of and negative attitudes towards same-sex sexuality. Disclosure of sexual orientation may be self-affirming, but could increase exposure to negative responses and stressors. Outcomes of an online survey among 110 gay and bisexual Jamaican men ages 18 to 56 years suggest that disclosure to family is affected by level of economic independence. Furthermore, negative familial responses to sexual identity significantly predicted depression. Social and structural interventions, and efforts to strengthen positive family relationships, are needed to foster an environment that enables well-being among sexual minorities in Jamaica.

Transfer is not a transition – voices of Jamaican adolescents with HIV and their health care providers

ABSTRACT Increasing access to antiretroviral therapy in resource-limited settings (RLS) has resulted in the survival of perinatally HIV-infected children into adulthood. We characterized the transition process from pediatric to adult care by conducting semi-structured interviews of HIV-infected adolescents and health care providers in Jamaica. Using an inductive content analytic approach, four themes emerged: (1) Transition should be holistic and a process; (2) Pediatric clinics were like families; (3) Rootedness in the pediatric clinic; and (4) Need for adolescent-centered services to bridge the gap between pediatric and adult-centered services. Adolescent informed- and centered-transition approach may result in better outcomes for HIV-infected adolescents.

Paediatric critical care: beyond the walls

mechanisms with the potential to result in the failure of one or more organ systems, incomplete recovery or death, without prompt and appropriate intervention (1, 2). Recognition and management are particularly challenging in infants and children, because of the age-specific differences in types of illness and range of physiologic values, the skill required to perform procedures on small children, and the unanticipated sudden deterioration especially in infants who have limited compensatory capacity. The old adage that ‘children are not little adults’ is applicable, and the value of specific knowledge and training in paediatric critical care management by pertinent personnel cannot be understated (3). Critically ill children present in diverse settings, including the prehospital (primary care physician’s office, public health centres and unexpected emergent circumstances) and hospital environments (emergency department, ward and intensive care facility). The spectrum of clinical problems presenting as critical illness include infections and sepsis, respiratory, cardiovascular and neurological emergencies, trauma and post-surgical supportive care. Outcome of critical illness in children hinges on early recognition, expeditious anticipatory supportive intervention and prompt definitive treatment. When one considers the diversity of possible settings in which critically ill children may present, common sense would dictate that basic intensive care for such children begins whenever resuscitation occurs or coincides with the anticipated need for advanced care. It is incumbent on caregivers and healthcare providers to be able to deliver appropriate care whenever the need arises. Optimum care, however, depends on the level of training and experience of the individual, the available resources in the facility, quality of transport service, the existence of appropriate tertiary-level care with required expertise and use of evidence-based management protocols. In Jamaica, children (0–17 years old) comprise 37.6% (986 713) of the total population. This figure increases to 41.4% (1 087 649) when 18and 19-year-olds are included (4). Respiratory conditions, gastrointestinal infections and diarrhoea, septicaemia and inflammatory conditions of the central nervous system rank as the commonest discharge diagnoses in infants and children less than four years. Burns, corrosions and poisonings are commonest in the one to four year band; intentional accidents and intracranial injuries are increasingly common discharge diagnoses in older children and adolescents (5). Most deaths occur as a result of respiratory infections, diarrhoea and gastrointestinal infections, and septicaemia, particularly in the less than four-year age group (5). These common conditions represent potential risk opportunities for intensive care interventions in the paediatric population. A number of these problems are preventable and thus underscores the value of public health preventive strategies to improve the current epidemiologic profile. There are currently 22 available intensive care beds distributed among the four major hospitals in Jamaica: The University Hospital of the West Indies (UHWI), Kingston Public Hospital (KPH), Bustamante Hospital for Children (BHC) and Cornwall Regional Hospital (CRH). Only the unit at BHC and the neonatal intensive care unit at UHWI are dedicated to paediatric intensive care, and have a functional bed capacity of eight beds; UHWI, KPH and CRH have general intensive care units. The estimated intensive care need for the paediatric population (birth to 18 years) in Jamaica is approximately 26 beds (bed requirement = m + 1.64 m where m = p x 20/1 000 000; p is the at risk population) (6). The disparity between available resources and burden of need suggests that many children in Jamaica will be denied access to optimized paediatric intensive care. In fact, critically ill children are often managed on the wards where conditions are constrained and access to the intensive care unit (ICU) is based on reactionary rather than anticipatory criteria (7, 8). Research has shown that optimal paediatric ICU care is best provided in centralized tertiary care units, with the relevant expertise (9, 10). But can we really afford to provide this kind of care, given the competing health needs and limited economic and infrastructural resources within the health sector? An assessment of the intensive care needs at the general intensive care unit, UHWI, during the period June 2001 to May 2002, confirmed that the demand outstripped the supply and that mortality was high among those nonadmitted patients who were considered suitable candidates for ICU care (7, 8). Among 56 ICU admission requests (in the Paediatric Critical Care Beyond the Walls RB Pierre1, R Augier2 EDITORIAL