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ObjectiveDetermine non-invasive ventilation with continuous positive airway pressure (CPAP) outcomes for paediatric respiratory distress in low-income and middle-income countries (LMICs).DesignSystematic review and meta-analysis.SettingLMIC hospitals.PatientsOne month to 15 year olds with respiratory distress.InterventionsWe searched Medline, Embase, LILACS, Web of Science and Scopus on 7 April 2020. Included studies assessed CPAP safety, efficacy or effectiveness. All study types were included; neonatal only studies were excluded. Data were extracted by two reviewers and bias was assessed. Certainty of evidence was evaluated, and risk ratios (RR) were produced for meta-analyses. (PROSPERO protocol CRD42018084278).Results2174 papers were screened, 20 were included in the systematic review and 3 were included in two separate meta-analyses of mortality and adverse events. Studies suitable for meta-analysis were randomised controlled trials (RCTs) from Bangladesh, Ghana and Malawi. For meta-analyses comparing death or adverse events between CPAP and low-flow oxygen recipients, we found no clear CPAP effect on mortality (RR 0.75, 95% CI 0.33 to 1.72) or adverse events (RR 1.52, CI 0.71 to 3.26). We downgraded the certainty of evidence for both death and adverse events outcomes to ‘low’ due to design issues and results discrepancies across RCTs.ConclusionsEvidence for CPAP efficacy against mortality and adverse events has low certainty and is context dependent. Hospitals introducing CPAP need to have mechanisms in place to optimise safety in the context it is being used; this includes the location (a high dependency or intensive care area), adequate numbers of staff trained in CPAP use, close monitoring and mechanisms for escalation, daily direct physician supervision, equipment that is age appropriate and user-friendly and continuous monitoring of outcomes and quality of care.

Background An increasing number of medical trainees across specialties desire and expect Global Health (GH) experiences during training. It is useful for residency programs to know the impact that offering GH opportunities has on resident recruitment. The study objectives were to explore the importance of GH opportunities in residency selection among fourth-year medical students, examine the relationship between interest in GH and career plans, and describe students’ perspectives on prior GH experiences. Methods The authors administered an electronic survey to all fourth-year medical students attending 12 different US institutions in February 2020. Data from the ten schools who were able to comply with the survey distribution methodology and with response rates above 25% were analyzed using descriptive statistics and Pearson’s correlation. Results A total of 707 fourth-year medical students from the included schools completed the survey out of 1554 possible students (46% response rate). One third of respondents ranked the presence of GH experiences in residency as moderately or very important and 26% felt that the presence of a formal GH curriculum was at least moderately important, with variation noted among specialties. After training, 65% of students envision practicing internationally in some capacity. A desire to care for underserved patients in their careers was significantly correlated with an interest in GH experiences during residency. Conclusions The opportunity to be involved in GH experiences during training can be an important factor for many medical students when considering residency choice, and the availability of these opportunities may be a valuable recruitment tool. Students valuing GH opportunities during residency are more interested in working with underserved populations in their future careers.

Selective serotonin reuptake inhibitors are a commonly used and often effective class of medications in the treatment of mood disorders such as anxiety and depression. Sertraline (1S,4S-N-methyl-4-[3,4-dichlorophenyl]-1,2,3,4-tetrahydro-1-naphthylamine [Zoloft; Pfizer, New York City, NY]) is a frequently used selective serotonin reuptake inhibitor that has shown efficacy in children, adolescents, and adults. We report the case of a 13-year-old boy with sertraline-induced rhabdomyolysis and renal failure, trismus, and cardiopulmonary arrest. Pharmacogenetic testing later revealed our patient had serotonin transporter polymorphisms and enzymatic alterations that put him at risk for increased levels of sertraline and greater likelihood for untoward side effects.

Background United States (U.S.) census data from 2017 indicates that the percentage of persons born outside of the U.S. is increasing. However, no studies describe the amount of class time focused on immigrant and refugee health during medical school in the U.S. nor on incoming residents’ confidence in providing culturally sensitive care. The objective of this study is to characterize final-year medical students’ exposure to immigrant and refugee health and their confidence in caring for these populations. Methods A voluntary, cross-sectional survey was sent electronically to fourth-year medical students at twelve U.S. medical schools in 2020, with 707 respondents (46% response rate). Questions addressed respondents’ curricular exposure to immigrant and refugee health care during medical school and their confidence in providing culturally sensitive care. Chi-square tests were used to assess relationships between categorical variables, and odds ratios were calculated for dichotomized variables. Results Most students (70.6%) described insufficient class time dedicated to culturally sensitive care, and many (64.5%) reported insufficient clinical exposure in caring for immigrants/refugees. The odds that incoming residents felt ‘usually’ or ‘always’ confident in their ability to provide culturally sensitive care to immigrants and refugees were higher in those with more class time on culturally sensitive care (OR 5.2 [3.6–7.4]), those with more clinical opportunities to care for immigrants and refugees (OR 7.2 [5.1–10.2]), and those who participated in a domestic low-resource or international elective (OR 1.4 [1.02–1.9]). More than half (55.3%) of respondents reported feeling ‘not at all’ or only ‘sometimes’ confident in their ability to provide culturally sensitive care to immigrants/refugees. Conclusions Most fourth-year U.S. medical students entering residency feel unprepared to deliver culturally sensitive care to immigrants and refugees. This may be mediated by increased exposure to didactic curricula class time and/or experiential clinical activities, as those factors are associated with improved student confidence

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Background Lower respiratory tract infections (LRTIs) are a leading cause of under-5 mortality in low-income and middle-income countries (LMICs) and interventions to reduce mortality are needed. Non-invasive ventilation has been shown to reduce mortality for neonates; however, data for children >1 month of age in LMICs are lacking. The objective of this study was to systematically review the available literature to determine if non-invasive ventilation as the primary modality of respiratory support is efficacious and safe for the management of respiratory distress in non-neonatal pediatric patients in LMICs. Methods We systematically reviewed all studies assessing the endpoints of efficacy, effectiveness, and safety of non-invasive ventilation for pediatric LRTIs in LMICs. A comprehensive search of Medline, Embase, LILACS, Web of Science, and Scopus was performed on April 7, 2020. Included studies assessed the safety, efficacy or effectiveness of non-invasive ventilation (NIV) in the hospital setting for pediatric patients with respiratory distress from 1 month - 15 years of age in LMICs. All study types, including case reports and case series were included. Studies focusing exclusively on neonates (<28 days old) were excluded. Mortality and rates of adverse events were extracted using Covidence by two independent reviewers. Risk of bias was assessed using GRADE criteria for randomized control trials and a standardized risk of bias assessment tool for observational studies. The study protocol was registered on PROSPERO (CRD42018084278). Findings A total of 2174 papers were screened and 20 met criteria for inclusion. There were 5 randomized control trials (RCTs), including 3 large, well-designed RCTs. The first RCT, the "Bangladesh trial," found that children who received bubble continuous positive airway pressure (bCPAP) compared to low-flow oxygen had a significantly lower risk of failure (6% in CPAP and 24% in low-flow oxygen, p=0.0026) and mortality (4% in CPAP and 15% in low-flow oxygen, p=0.022). A second RCT, the "Ghana trial," found no decrease in all-cause mortality between the CPAP and control arms (3% and 4% respectively, p=0.11); however, an adjusted secondary analysis demonstrated decreased mortality for children under 1 year of age (3% in CPAP and 7% in control group, p=0.01). The third RCT, the "Malawi trial," compared bCPAP to low flow oxygen and found higher mortality in the bCPAP arm (17% and 11% respectively, p=0.036). Among the non-RCT studies, mortality rates ranged from 0-55%. Interpretation The evidence of efficacy, effectiveness, and safety is mixed regarding the use of NIV in children with respiratory failure in LMICs. Our review of the literature suggests that CPAP for non-neonatal pediatric patients should be considered only in well-controlled, high acuity units with high provider-to-patient ratios and direct physician supervision. Until further data are available, CPAP use in LMICs should be limited to children less than 1 year of age. Further research is needed to determine best practices for CPAP prior to wide-spread implementation. Funding There was no funding source for this study.