Pediatric Clinical Objectives Journal Analysis
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Only 7. Streptokinase was equally effective if started before or after seven days. Conclusions: Intrapleural Streptokinase is the preferred treatment for treating pediatric empyema thoracis even in advanced stages and can avoid surgery. Pediatrics Empyema Thoracis Streptokinase. Empyema thoracis is an uncommon complication of childhood pneumonia and general pediatricians may only see a few cases in their career 1. Although mortality rates in pediatric empyema thoracis are very low, empyema thoracis causes significant morbidity including substantial health care costs and burden of care. Childhood empyema thoracis occurs in 0. Recent studies in countries such as USA, Canada, Spain, France, Scotland and England have suggested that the number of cases of childhood empyema thoracis have been increasing.
The cause for this is unclear but a number of reasons have been postulated, including a decrease in antibiotic use in primary care. Another suggestion has been that the rise is related to the introduction of the 7-valent pneumococcal vaccine 7v PVC into national immunization programs which has led to an increase in invasive pneumococcal empyema thoracis disease caused by non-vaccine serotypes 3 - This view is in contrast to a number of studies throughout the world, including Australia, which has shown an increase in the prevalence of empyema thoracis prior to the introduction of the 7v PVC 1 , 15 , Many treatment options are available, however due to a lack of quality research there is limited high grade evidence to direct best standards of care.
It is unclear whether optimal management is closed tube drainage or video assisted thoraco-scopic surgery VATS followed by chest tube drainage In our country VATS is not widely available, so on failure of medical treatment, open decortication is often needed. As per newer guidelines isolated intercostal tube drainage without fibrinolytics preferably be avoided In our study we wanted to show the role of intrapleural streptokinase in an attempt to reduce the need for surgery which is costly and cumbersome. We want to reveal the age and sex distribution of empyema thoracis patients, organism pattern, relation of outcome to the different time of initiation of intrapleural streptokinase and difference in ultimate outcome in terms of clinical and radiological resolution.
A prospective study was done on children aged 0 to 12 years with features of empyema thoracis attended in our tertiary care hospital Pediatric Intensive Care Unit in the time frame of December to November Decision for insertion of chest tube was taken depending upon clinical condition of patients and radiologic and laboratory evidence. Fluid was aspirated in all cases and examined by naked eye and was sent for routine and microscopic examination protein, lactic dehydrogenase, glucose, total cells, differential count, cytological examination and pH along with culture sensitivity.
Consent was taken from legal guardians in preformed proforma after proper counselling and approval was taken from institutional Ethical committee prior to study and publication. Duration of infusion was one hour and clamping was done for four hours and then free drainage was allowed. Duration of infusion varied from three to twelve days depending on regular clinical check-up, regular ultrasound assessment and chest x-ray, the latter was done every three days until resolution occurred.
Intravenous antibiotics and supportive management were continued as per our institutional protocol. After removal of chest drain repeat x-ray was done immediately and after one month, three months and six months. In two patients re-insertion of chest tube was needed with prolongation of intrapleural streptokinase administration. Two cases not responding clinically and radiologically were referred to cardiovascular surgery department. Response to treatment was defined as reduction of respiratory distress, improvement of clinical finding in the form of better air entry and improvement of x-ray and ultrasonography finding.
Resolution was defined as complete or near complete disappearance of opacity on chest x-ray and insignificant fluid in pleural space on USG. Data were tabulated and statistical analyses were performed with help of Epi Info TM 3. Using this software, basic cross-tabulation, inferences and associations were performed. Among the study population Staphylococcus aureus was detected in majority In this study Two of the early starters and sixteen of late starters had multiloculated empyema thoracis on USG.
Out of 28 patients only two 7. In each age group intrapleural streptokinase is significantly successful in reducing the need for surgery. Two patients who required decortication surgery were positive for Pnemococcus and Staphylococcus aureus in pleural fluid culture. All patients were followed up for six months as per protocol and all showed resolution on chest x-ray. During our study no major complication except bleeding from tube insertion site in three patients needing pressure and stitch occurred. Empyema thoracis is an accumulation of pus in pleural space.
It is most often associated with pneumonia due to Streptococcus pneumoniae , although Staphylococcus aureus is most common in developing nations and Asia Haemophilus influenzae , group A Streptococcus , gram negative organisms, tuberculosis, fungi, malignancy and trauma are other causes. Empyema thoracis consists of three stages-exudative phase fibrinous exudates forms on pleural surfaces , fibrinopurulent phase fibrinous septa form, causing lobulation and thickening of parietal pleura , and organization phase. If pus is not drained in second phase it may dissect through pleura into lung parenchyma leading to bronchopleural fistula BPF , pyopneumothorax, in abdominal cavity or through chest wal l empyaema necessitates. If organized lung may collapse and become surrounded by thick inelastic peel.
Option for drainage is controversial. Some experts are in favor of VATS followed by chest tube drainage, some experts opine in favor of closed tube drainage with or without fibrinolytics, some think of early decortication We wanted to reveal the role of intrapleural streptokinase in management of pediatric empyema thoracis and also its role in reducing the number of surgery. Often cases are referred to the tertiary care hospital after several days of onset of symptoms. In this study statistically significant number of cases was referred late 9 vs.
One of our patients was started streptokinase even on 23rd day of illness and showed complete resolution. Decortication was needed in two patients only both of them were started streptokinase after 7 days as they were referred late but rest 17 cases in this group were successfully managed by medical treatment. All 9 patients who were administered streptokinase before 7 days needed no surgery. Only 2 patients out of 26 7. Failure rate in our study is less than in other studies. In other studies it is Statistical significance of medical management over surgery has been demonstrated in this study.
Similar result was demonstrated by Sonnappa et al. A recent meta-analysis of 10 trials 25 reported that intrapleural fibrinolytics reduced the need for surgery and duration of hospitalization. Some are still favoring surgery. If one were to leap immediately to pharmacotherapeutics without first knowing and understanding the foundational material, the quality of learning, the ability to transfer learning to different situations and the ability to manage specific patient requirements is likely to be compromised.
The foundation of the pyramid is knowledge, followed by understanding. Each subsequent layer of the pyramid builds upon these foundations. Failure to adequately build these foundations leads to incomplete acquisition of knowledge and skills over time, which may result in performance problems, such as an inability to apply learning in new or different contexts or situations. The model illustrates that learning builds in a step-wise, progressive manner — each preceding stage is required to support more advanced forms of learning.
Early levels representing knowledge acquisition and understanding provide the foundation for later levels related to application, evaluation, and creation of new knowledge. Clinical teachers designing learning objectives use their experience to deconstruct and analyse how an individual develops from a novice to a competent and confident practitioner [10]. Reflecting on and then articulating this process is a skill that can be developed [11]. It is helpful to use the taxonomy as a starting point and think about each layer of the pyramid and what critical content is required at that level. Goal: To be competent and confident in adjusting insulin doses based on blood glucose levels for patients with diabetes.
Example: After the first four weeks of this rotation, students should be able to list common signs and symptoms of diabetes. Example: At the end of this rotation, students should be able to describe the significance of laboratory test values including fasting blood glucose and HgA1C in establishing treatment goals for diabetes management. Example: At the end of this rotation, students will be able to calculate appropriate modified insulin doses for patients without comorbidities, using clinical laboratory findings.
Example: After the first week of this rotation, students should be able to appraise primary literature related to diabetes management using a systematic approach. Example: At the end of this rotation, students will be able to predict and justify anticipated clinical outcomes associated with their insulin dose modification recommendations. Example: At the end of this rotation, students will be able to design patient-specific education and monitoring tools to support self-management of insulin dosing.
SMART is an acronym outlining key attributes of the most effective types of learning objectives. It is usually best to focus on a single activity or task within each learning objective. Specific number, date and patient population identified to allow the student to remain on-track and on-task. Develop, justify and gain agreement from the medical team for pharmacy care plan recommendations for ten patients. Quality here can be defined through justification and acknowledgement from the medical team. Review profiles and identify potential or actual drug therapy problems for all patients aged over 65 years receiving two or more drugs identified as potential risk using Beers Criteria during September.
Lack of specificity compromises quality of learning objective. Define, list, recall, recognise, state, repeat, arrange, match, order, reproduce, replicate. Discuss, describe, explain, translate, restate, report, recognise, distinguish, estimate, indicate, select, sort. Demonstrate, illustrate, perform, interpret, apply, employ, use, practice, prepare, modify, predict, extrapolate, manage, solve, choose. Distinguish, differentiate, calculate, compare, contrast, categorise, appraise, relate, solve, examine, outline. Evaluate, assess, justify, appraise, argue, decide, criticise, defend, judge, predict, value. Make, propose, design, hypothesise, construct, invent, generate, synthesise, formulate, plan, compose. Learning objectives can also provide a roadmap for evaluating students [12].
Formative assessment provides students with low-judgement feedback focused on quality improvement and professional development rather than grades or ranking. Using learning objectives to guide formative assessment is both effective and fair: students should know upfront what is expected of them by simply reading the objectives, and teachers can use the targets as a way of structuring questioning, discussion and dialogue more efficiently. Summative assessment is a more evaluative, judgmental form of evaluation, usually associated with a grade, a pass or fail decision, or ranking students in order of achievement.
Examples of summative assessments include traditional tests and quizzes, objective structured clinical examinations OSCEs and research papers. In general, students should have frequent opportunities to receive formative assessment of their progress through learning objectives before having to perform in summative assessment. In this way, they can receive supportive feedback and coaching about areas for improvement and be better prepared for examinations. SMART learning objectives should provide a roadmap for formative and summative assessment.
Any of these methods can be summative or formative, depending upon context and requirements. Tailoring a lesson or clinical rotation to make best use of learning objectives is important. Learning objectives are merely words on a page and require clinical teachers to bring them to life. Central to this process is the initial dialogue between teacher and student when the learning objectives are introduced, explaining how they will be used in the classroom or clinical setting [10]. Helping students understand the logical progression of objectives and clarifying which assessment methods will be used is essential [10]. It is helpful to identify specific, recurrent times and dates for future discussions related to completing learning objectives, since this will foster accountability for learning and enhance predictability for students.
If students perceive that teachers are serious about using learning objectives, they will orient their behaviours accordingly [10], [11]. Identifying problems or misconceptions early in the process means they can be remedied through corrective feedback to prevent them being perpetuated in future learning. Learning objectives should reflect the strengths, needs and interests of teachers and students alike.
More important than the written objectives themselves is the engagement between student and teacher that they produce: objectives will only work to support learning if they are used in an authentic manner and students and teachers commit to their use. When used in this way, they can provide a structure for teaching and learning, a platform for dialogue and discussion between teacher and student, and a roadmap for how to build knowledge, clinical skills and professional behaviours. You can use the following forms to record your learning and action points from this article from Pharmaceutical Journal Publications.
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