Short term Outcomes of COVID-19 Vaccines Among Lactating Mother and Child Dyads in Bangladesh: A Multi-centre, Cross-sectional Study

INTRODUCTION

The aims of the study are to: (1) determine the short-term reactogenicity of WHO-approved COVID-19 vaccines (i.e., Pfizer-BioNTech, Moderna, Sinovac, Oxford-AstraZeneca, Johnson and Johnson, Covaxin) amongst lactating women and their children, and 2) evaluate lactation-related outcomes following the same vaccines in Bangladesh.

METHODS

This was a multi-centre, self-reported, cross-sectional study of lactating woman-child dyads in Bangladesh. Demographics, past medical history, breastfeeding history and clinical outcomes of lactating woman-child dyads at least 7 days after the last dose of vaccine were determined through a structured questionnaire.

RESULTS

There were 750 participants from four centres. The mean age of lactating women and children surveyed were 27.6 (SD ± 4.6) years and 10.3 (SD ± 6.7) months, respectively. Majority (81.2%; 608 of 750) received 2 doses of COVID-19 vaccinations while lactating. Almost all (99.9%; 749 of 750) vaccinated lactating women surveyed reported no change in human milk supply. More than half of the participants (56.9%; 373 of 656) reported no symptoms after both doses of COVID-19 vaccines. There were no serious adverse events such as anaphylaxis or hospital admission. Majority of the lactating women (98.9%; 742 of 750) reported that the children whom they breastfed had no symptoms such as fever or cough.

DISCUSSION

This large study of lactating woman-child dyads in Bangladesh, who received a diverse range of WHO-approved COVID-19 vaccines, showed no serious short-term adverse effects.

PRECIOUS demonstrated satisfactory measurement properties for assessing the quality of care for children with serious illnesses

OBJECTIVES

To determine the measurement properties of PaRental Experience with care for Children with serIOUS illnesses (PRECIOUS), a parent-reported measure of Quality of Care for seriously ill children across care settings and illness trajectories.

STUDY DESIGN AND SETTING

Parents self-administered baseline and 2-week follow-up surveys online. Exploratory Factor Analysis was used to determine PRECIOUS's factor structure and select items. Internal consistency was evaluated with Cronbach's α, test-retest reliability with intraclass correlation coefficients, and convergent validity with Spearman's correlations between PRECIOUS scales and subscales of Measure of Processes of Care and Quality of Children's Palliative Care Instrument.

RESULTS

Of 152 parents [108 (71%) mothers, 44 (29%) fathers] who completed the baseline survey, 123 (81%) completed follow-up. Exploratory Factor Analysis grouped PRECIOUS into five scales: collaborative and goal-concordant care (12 items), caregiver support and respectful care (15 items), access to financial and medical resources (five items), reducing caregiving stressors (nine items), and hospitalization-specific processes (four items). Root Mean Square Error of Approximation was 0.040 and Comparative Fit Index was 0.980. Cronbach's α ranged from 0.85 to 0.96. Intraclass correlation coefficients ranged from 0.72 to 0.86. Significant correlations with Measure of Processes of Care and Quality of Children's Palliative Care Instrument confirmed convergent validity. The original 56-item tool was reduced to 45 items.

CONCLUSION

PRECIOUS demonstrates satisfactory measurement properties for assessing Quality of Care for seriously ill children.

Knowledge, attitudes, practices, and perceived challenges for healthcare workers on waterless intensive care unit (ICU) care at a neonatal ICU in Singapore

BACKGROUND

Implementation of waterless care, including removal of sinks from patient care areas, is an emerging approach to reduce waterborne infections in high-risk areas such as intensive care units (ICUs). This approach, however, requires significant changes from traditional infection control practices and acceptance by healthcare workers (HCWs) for successful transition.

AIM

To explore the knowledge, attitudes, practices (KAPs), and perceived challenges of HCWs who transitioned from working in a unit with standard infection control practices to one with waterless ICU care practices.

METHODS

The study was conducted using a customized 30-item self-reported survey instrument administered to HCWs working in tertiary neonatal units at a single hospital.

FINDINGS

Participation rate was 88.6% (101/114), comprising 66.3% (67/101) nurses, 31.0% (31/101) doctors, and 3.0% (3/101) allied health professionals; 90.1% (91/101) had positive attitudes and 53.5% (54/101) had good knowledge regarding waterless ICU care; 83.1% (84/101) followed the appropriate practice of hand hygiene when their hands were visibly soiled. Main challenges with waterless ICU care were perceived compromise of personal (46.5% (47/101)) and patient (22.8% (23/101)) hygiene. A total of 43.6% (44/101) reported an increase in skin-related conditions: 10.9% (11/101) had to visit a doctor for this reason, of whom 64.0% (7/11) had pre-existing skin conditions.

CONCLUSION

Despite overall good attitudes and practices toward waterless ICU care, HCWs may have specific concerns related to hygiene and skin conditions which need to be addressed. For units transiting to waterless ICU care, similar surveys may provide valuable information by identifying gaps in KAP to improve compliance.

Development of the Parental Experience with Care for Children with Serious Illnesses (PRECIOUS) quality of care measure

BACKGROUND

Parent-reported experience measures are part of pediatric Quality of Care (QoC) assessments. However, existing measures were not developed for use across multiple healthcare settings or throughout the illness trajectory of seriously ill children. Formative work involving in-depth interviews with parents of children with serious illnesses generated 66 draft items describing key QoC processes. Our present aim is to develop a comprehensive parent-reported experience measure of QoC for children with serious illnesses and evaluate its content validity and feasibility.

METHODS

For evaluating content validity, we conducted a three-round Delphi expert panel review with 24 multi-disciplinary experts. Next, we pre-tested the items and instructions with 12 parents via cognitive interviews to refine clarity and understandability. Finally, we pilot-tested the full measure with 30 parents using self-administered online surveys to finalize the structure and content.

RESULTS

The Delphi expert panel review reached consensus on 68 items. Pre-testing with parents of seriously ill children led to consolidation of some items. Pilot-testing supported feasibility of the measure, resulting in a comprehensive measure comprising 56 process assessment items, categorized under ten subthemes and four themes: (1) Professional qualities of healthcare workers, (2) Supporting parent-caregivers, (3) Collaborative and holistic care, and (4) Efficient healthcare structures and standards. We named this measure the PaRental Experience with care for Children with serIOUS illnesses (PRECIOUS).

CONCLUSIONS

PRECIOUS is the first comprehensive measure and has the potential to standardize assessment of QoC for seriously ill children from parental perspectives. PRECIOUS allows for QoC process evaluation across contexts (such as geographic location or care setting), different healthcare workers, and over the illness trajectory for children suffering from a range of serious illnesses.

Contemporary fluid management, humidity, and patent ductus arteriosus management strategy for premature infants among 336 hospitals in Asia

Objectives

The management of patent ductus arteriosus (PDA) is a critical concern in premature infants, and different hospitals may have varying treatment policies, fluid management strategies, and incubator humidity. The Asian Neonatal Network Collaboration (AsianNeo) collected data on prematurity care details from hospitals across Asian countries. The aim of this study was to provide a survey of the current practices in the management of PDA in premature infants in Asian countries.

Methods

AsianNeo performed a cross-sectional international questionnaire survey in 2022 to assess the human and physical resources of hospitals and clinical management of very preterm infants. The survey covered various aspects of hospitals resources and clinical management, and data were collected from 337 hospitals across Asia. The data collected were used to compare hospitals resources and clinical management of preterm infants between areas and economic status.

Results

The policy of PDA management for preterm infants varied across Asian countries in AsianNeo. Hospitals in Northeast Asia were more likely to perform PDA ligation (p < 0.001) than hospitals in Southeast Asia. Hospitals in Northeast Asia had stricter fluid restrictions in the first 24 h after birth for infants born at <29 weeks gestation (p < 0.001) and on day 14 after birth for infants born at <29 weeks gestation (p < 0.001) compared to hospitals in Southeast Asia. Hospitals in Northeast Asia also had a more humidified environment for infants born between 24 weeks gestation and 25 weeks gestation in the first 72 h after birth (p < 0.001). A logistic regression model predicted that hospitals were more likely to perform PDA ligation for PDA when the hospitals had a stricter fluid planning on day 14 after birth [Odds ratio (OR) of 1.70, p = 0.048], more incubator humidity settings (<80% vs. 80%-89%, OR of 3.35, p = 0.012 and <80% vs. 90%-100%, OR of 5.31, p < 0.001).

Conclusions

In advanced economies and Northeast Asia, neonatologists tend to adopt a more conservative approach towards fluid management, maintain higher incubator humidity settings and inclined to perform surgical ligation for PDA.

Experiences of healthcare personnel with death in the neonatal intensive care unit: a systematic review of qualitative studies

OBJECTIVE

To synthesise evidence from qualitative studies on the experiences of healthcare personnel (HCP) in the neonatal intensive care unit (NICU) caring for dying neonates.

METHODS

We conducted a systematic search, in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines (PROSPERO: CRD42021250015), of four databases (PubMed, Embase, PsycINFO and CINAHL) from date of inception of the databases to 31 December 2021 using MeSH terms and related keywords. Data were analysed using three-step inductive thematic synthesis. Quality assessment of included studies was performed.

RESULTS

Thirty-two articles were included. There were 775 participants, majority (92.6%) of whom were nurses and doctors. Quality of studies was variable. The narratives of HCP coalesced into three themes: sources of distress, coping methods and the way forward. Sources of distress encompassed HCP's discomfort with neonatal deaths; poor communication among HCP and with patient's family; lack of support (from organisations, peers and HCP's family) and emotional responses (guilt, helplessness and compassion fatigue). Methods of coping included setting emotional boundaries, support from colleagues, clear communication and compassionate care and well-designed end-of-life workflows. Steps taken by HCP to move forward and overcome the emotionally turbulent effects of NICU deaths included finding meaning in death, building deeper relationship with patients' families and the NICU team and embracing purpose and pride in work.

CONCLUSION

HCP face several challenges when a death occurs in the NICU. HCP can provide better end-of-life care if their undesirable experiences with death are mitigated by better understanding and overcoming factors causing distress.

A qualitative exploration of parental perspectives on quality of care for children with serious illnesses

Introduction

Being responsive to end-users is essential to good care. Limited in-depth exploration of parental perspectives on care received by children over the course of serious illness has hindered the development of process measures to evaluate quality of care. Our objective was to identify the key process indicators prioritized by parents in the care of seriously ill young children and develop a framework to guide assessment of quality of care.

Methods

This qualitative study followed Charmaz's Constructivist Grounded Theory. In-depth semi-structured interviews were conducted with parents of young children with serious illness in Singapore. Participants were sampled across various healthcare settings, children's ages, and illness categories. Theoretical sampling and constant comparative analysis were used to generate initial, focused, and theoretical codes, which informed construction of a conceptual framework.

Results

31 parents participated from July 2021 to February 2022. Initial and focused coding generated 64 quality of care indicators describing key care practices, interactions, and procedures. Indicators were categorized under four themes: (1) efficient healthcare structures and standards, (2) professional qualities of healthcare workers, 3. supporting parent-caregivers, and 4. collaborative and holistic care. Theoretical coding led to the development of the "PaRental perspectives on qualIty of care for Children with sErious iLlnESSes (PRICELESS)" framework which summarizes elements contributing to the parental perception of quality of care.

Discussion

The identified process indicators will facilitate the development of standardised parent-reported measures for assessing service quality and benchmarking among providers. The framework provides overall guidance for conceiving quality improvement initiatives.

Birth anthropometry among three Asian racial groups in Singapore: proposed new growth charts

OBJECTIVE

We analysed birth anthropometry of babies of Chinese, Malay and Indian ancestry living in Singapore with an aim to develop gestational age (GA) and gender-specific birth anthropometry charts and compare these with the widely used Fenton charts.

DESIGN

Retrospective observational study.

SETTING

Department of Neonatology, National University Hospital, Singapore.

POPULATION

We report data from 52 220 infants, born between 1991-1997 and 2010-2017 in Singapore.

METHODS

Anthropometry charts were built using smoothened centile curves and compared with Fenton's using binomial test. Birth weight (BW), crown-heel length and head circumference (HC) were each modelled with maternal exposures using general additive model.

MAIN OUTCOME MEASURES

BW, crown-heel length and HC.

RESULTS

There were 22 248 Chinese (43%), 16 006 Malay (31%) and 8543 Indian (16%) babies. Mean BW was 3103 g (95% CI 3096 to 3109), 3075 g (95% CI 3067 to 3083) and 3052 g (95% CI 3041 to 3062) for Chinese, Malays and Indians, respectively. When exposed to a uniform socioeconomic environment, intrauterine growth and birth anthropometry of studied races were almost identical. From our GA-specific anthropometric charts until about late prematurity, Asian growth curves mirrored that of Fenton's; thereafter, Asian babies showed a reduction in growth velocity.

CONCLUSIONS

These findings suggest that Asian babies living in relatively uniform socioeconomic strata exhibit similar growth patterns. There is a slowing of growth among Asian babies towards term, prompting review of existing birth anthropometry charts. The proposed charts will increase accuracy of identification of true fetal growth restriction as well as true postnatal growth failure in preterm infants when applied to the appropriate population.

Antenatal corticosteroids in Singapore: A clinical and scientific assessment

Preterm birth (PTB; delivery prior to 37 weeks' gestation) is the leading cause of early childhood death in Singapore today. Approximately 9% of Singaporean babies are born preterm; the PTB rate is likely to increase given the increased use of assisted reproduction technologies, changes in the incidence of gestational diabetes/high body mass index and the ageing maternal population. Antenatal administration of dexamethasone phosphate is a key component of the obstetric management of Singaporean women who are at risk of imminent preterm labour. Dexamethasone improves preterm outcomes by crossing the placenta to functionally mature the fetal lung. The dexamethasone regimen used in Singapore today affords a very high maternofetal drug exposure over a brief period of time. Drawing on clinical and experimental data, we reviewed the pharmacokinetic profile and pharmacodynamic effects of dexamethasone treatment regimen in Singapore, with a view to creating a development pipeline for optimising this critically important antenatal therapy.

Immune and pathophysiologic profiling of antenatal coronavirus disease 2019 in the GIFT cohort: A Singaporean case-control study

COVID-19 can be severe in pregnant women, and have adverse consequences for the subsequent infant. We profiled the post-infectious immune responses in maternal and child blood as well as breast milk in terms of antibody and cytokine expression and performed histopathological studies on placentae obtained from mothers convalescent from antenatal COVID-19. Seventeen mother-child dyads (8 cases of antenatal COVID-19 and 9 healthy unrelated controls; 34 individuals in total) were recruited to the Gestational Immunity For Transfer (GIFT) study. Maternal and infant blood, and breast milk samples were collected over the first year of life. All samples were analyzed for IgG and IgA against whole SARS-CoV-2 spike protein, the spike receptor-binding domain (RBD), and previously reported immunodominant epitopes, as well as cytokine levels. The placentae were examined microscopically. The study is registered at clinicaltrials.gov under the identifier NCT04802278. We found high levels of virus-specific IgG in convalescent mothers and similarly elevated titers in newborn children. Thus, antenatal SARS-CoV-2 infection led to high plasma titers of virus-specific antibodies in infants postnatally. However, this waned within 3-6 months of life. Virus neutralization by plasma was not uniformly achieved, and the presence of antibodies targeting known immunodominant epitopes did not assure neutralization. Virus-specific IgA levels were variable among convalescent individuals' sera and breast milk. Antibody transfer ratios and the decay of transplacentally transferred virus-specific antibodies in neonatal circulation resembled that for other pathogens. Convalescent mothers showed signs of chronic inflammation marked by persistently elevated IL17RA levels in their blood. Four placentae presented signs of acute inflammation, particularly in the subchorionic region, marked by neutrophil infiltration even though > 50 days had elapsed between virus clearance and delivery. Administration of a single dose of BNT162b2 mRNA vaccine to mothers convalescent from antenatal COVID-19 increased virus-specific IgG and IgA titers in breast milk, highlighting the importance of receiving the vaccine even after natural infection with the added benefit of enhanced passive immunity.

Mentoring a surgical team towards procedural competence in the early learning curve for selective fetoscopic laser photocoagulation

INTRODUCTION

Selective fetoscopic laser photocoagulation (SFLP) for twin-to-twin transfusion syndrome (TTTS) is challenging for new surgeons at the start of their learning curve. We described an approach utilising telementoring and team-based training to facilitate rapid attainment of the skills required for safe and efficient practice with a limited caseload.

METHODS

We conducted a prospective observational study of SFLP performed by the novice primary surgical team in three stages: under direct on-site supervision from an expert mentor (Group 1), with remote tele-guidance from that mentor (Group 2) and independently (Group 3), at an academic tertiary hospital in Singapore. The primary team undertook regular training on high-fidelity tissue models to accelerate skills acquisition and complement the surgical performance.

RESULTS

9 patients diagnosed with Stage 2 TTTS were assessed for procedural characteristics, surgical outcomes and perinatal survival following SFLP. There were no significant differences in operative duration, anastomoses ablated, gestational age or birth weight at delivery. The complications observed were: recurrent TTTS (22.2% of pregnancies), twin anaemia polycythaemia sequence (33.3%), preterm prelabour membrane rupture (22.2%) and delivery at < 32 weeks (44.4%). ≥ 1 twin was live-born in 88.9% of cases, while postnatal survival to six months of ≥ 1 twin occurred in 77.8% of cases.

CONCLUSION

Systematic mentoring and specialised skills training are useful in aiding new surgeons to negotiate the steep learning curve and achieve good outcomes at the start of a new practice, particularly in the setting of low patient numbers. This is best paired with dedicated model training to achieve and maintain surgical dexterity for this complex procedure.

Titres and neutralising capacity of SARS-CoV-2-specific antibodies in human milk: a systematic review

OBJECTIVE

Synthesise evidence on production of SARS-CoV-2 antibodies in human milk of individuals who had COVID-19, and antibodies' ability to neutralise SARS-CoV-2 infectivity.

DESIGN

A systematic review of studies published from 1 December 2019 to 16 February 2021 without study design restrictions.

SETTING

Data were sourced from PubMed, MEDLINE, Embase, CNKI, CINAHL and WHO COVID-19 database. Search was also performed through reviewing references of selected articles, Google Scholar and preprint servers. Studies that tested human milk for antibodies to SARS-CoV-2 were included.

PATIENTS

Individuals with COVID-19 infection and human milk tested for anti-SARS-CoV-2 neutralising antibodies.

MAIN OUTCOME MEASURES

The presence of neutralising antibodies in milk samples provided by individuals with COVID-19 infection.

RESULTS

Individual participant data from 161 persons (14 studies) were extracted and re-pooled. Milk from 133 (82.6%) individuals demonstrated the presence of anti-SARS-CoV-2 immunoglobulin A (IgA), IgM and/or IgG. Illness severity data were available in 146 individuals; 5 (3.4%) had severe disease, 128 (87.7%) had mild disease, while 13 (8.9%) were asymptomatic. Presence of neutralising antibodies in milk from 20 (41.7%) of 48 individuals neutralised SARS-CoV-2 infectivity in vitro. Neutralising capacity of antibodies was lost after Holder pasteurisation but preserved after high-pressure pasteurisation.

CONCLUSION

Human milk of lactating individuals after COVID-19 infection contains anti-SARS-CoV-2-specific IgG, IgM and/or IgA, even after mild or asymptomatic infection. Current evidence demonstrates that these antibodies can neutralise SARS-CoV-2 virus in vitro. Holder pasteurisation deactivates SARS-CoV-2-specific IgA, while high-pressure pasteurisation preserves the SARS-CoV-2-specific IgA function.

Breastfeeding Mother and Child Clinical Outcomes After COVID-19 Vaccination

BACKGROUND

Pre-approval clinical trials of the Pfizer/BioNTech messenger RNA COVID-19 vaccine, BNT162b2 did not include participants who were breastfeeding. Therefore, there is limited evidence about outcomes of breastfeeding mother-child dyads and effects on breastfeeding after vaccination.

RESEARCH AIMS

To determine: (1) solicited adverse effects (e.g., axillary lymphadenopathy, mastitis, and breast engorgement), which are unique to lactating individuals; and (2) systemic and local adverse effects of COVID-19 mRNA vaccine on mothers and potential effects on their breastfed infants.

METHOD

This was a prospective cohort study of lactating healthcare workers (N = 88) in Singapore who received two doses of BNT162b2 vaccination (Pfizer/BioNTech). The outcomes of mother-child dyads within 28 days after the second vaccine dose were determined through a participant-completed questionnaire.

RESULTS

Minimal effects related to breastfeeding were reported by this cohort; three of 88 (3.4%) participants had mastitis, one (1.1%) participant experienced breast engorgement, five of 88 (5.7%) participants reported cervical or axillary lymphadenopathy. There was no change in human milk supply after vaccination. The most common side effect was pain/redness/swelling at the injection site, which was experienced by 57 (64.8%) participants. There were no serious adverse events of anaphylaxis or hospital admissions. There were no short-term adverse effects reported in the infants of 67 lactating participants who breastfed within 72 hr after BNT162b2 vaccination.

CONCLUSIONS

BNT162b2 vaccination was well tolerated in lactating participants and was not associated with short-term adverse effects in their breastfed infants.

STUDY PROTOCOL REGISTRATION

The study protocol was registered at clinicaltrials.gov (NCT04802278).

Implementation research on kangaroo mother care, Bangladesh

Objective

To describe the implementation, coverage and performance of the national kangaroo mother care programme in Bangladesh.

Methods

Kangaroo mother care services for clinically stable babies with birth weight under 2000 g were set up in government-run health-care facilities in rural and urban areas of Bangladesh. Each facility provided counselling on kangaroo mother care, ensured adequate nutrition, and followed up mothers and babies. We studied implementation of the programme from January 2016 to March 2020 using data from the national database. We tracked the number of eligible babies enrolled and their outcomes, mortality and post-discharge follow-up.

Findings

The numbers of kangaroo mother care facilities increased from 16 in 2016 to 108 in 2020. Over the 4-year period 64 426 babies weighing under 2000 g were born in these facilities,  6410 of whom received kangaroo mother care. The quarterly percentage of eligible babies receiving kangaroo mother care increased from 4.7% (37/792) during the first quarter to 21.7% (917/4226) during the last five quarters of the programme. Deaths of babies receiving kangaroo mother care showed a downward trend over the study period. The overall mortality was 1.2% (77/6410), with large quarterly fluctuations in mortality. Post-discharge follow-up was low and only 15–20% of babies received four follow-up visits.

Conclusion

Implementation of kangaroo mother care interventions is feasible in low-resource settings. Such care has the potential to reduce mortality among low-birth-weight and premature babies. Challenges include low coverage, expanding the programme to the community and strengthening the monitoring system.

Juggling Multiple Roles amidst Uncertainty: The Asian Father's Perspective of an Infant in Neonatal Intensive Care Unit

OBJECTIVE

Parents of preterm, very low birthweight (VLBW) infants in neonatal intensive care units (NICU) undergo emotional turmoil. Studies on parent's experiences typically focus on the maternal perspective. The purpose of the study is to explore the emotional needs and experiences of fathers of VLBW neonates in the NICU and to identify ways to improve their experiences.

STUDY DESIGN

This was a qualitative descriptive design study undertaken at the NICU of a tertiary university hospital. Convenience sampling with predefined inclusion and exclusion criteria was used to identify prospective participants. Semi-structured interviews were conducted with 15 fathers of infants until data saturation was reached. The COREQ (Consolidated Criteria for Reporting Qualitative Studies) checklist was used.

RESULTS

Father's experiences were classified into the topics of concerns, roles, and perspectives. Uncertainty was a predominant theme in each of these. Fathers assume multiple roles toward the child, wife, self, and family. Their concerns were multifaceted involving the child, family, work, and finances; they experienced a myriad of emotions, but these evolved into resilience eventually.

CONCLUSION

Fathers have unique concerns pertinent to having an infant in the NICU. They juggle multiple roles and transition to emotions of resilience. It is imperative to acknowledge the uncertainty and diverse roles of fathers, provide them with customized information, and develop more balanced parent-support groups.

KEY POINTS

· Fathers juggle multiple roles with a child in NICU.. · Uncertainty is a key part of their experience.. · Acknowledging their role and emotions is important..

Codominant IgG and IgA expression with minimal vaccine mRNA in milk of BNT162b2 vaccinees

Lactating women can produce protective antibodies in their milk after vaccination, which has informed antenatal vaccination programs for diseases such as influenza and pertussis. However, whether SARS-CoV-2-specific antibodies are produced in human milk as a result of COVID-19 vaccination is still unclear. In this study, we show that lactating mothers who received the BNT162b2 vaccine secreted SARS-CoV-2-specific IgA and IgG antibodies into milk, with the most significant increase at 3-7 days post-dose 2. Virus-specific IgG titers were stable out to 4-6 weeks after dose 2. In contrast, SARS-CoV-2-specific IgA levels showed substantial decay. Vaccine mRNA was detected in few milk samples (maximum of 2 ng/ml), indicative of minimal transfer. Additionally, infants who consumed post-vaccination human milk had no reported adverse effects up to 28 days post-ingestion. Our results define the safety and efficacy profiles of the vaccine in this demographic and provide initial evidence for protective immunity conferred by milk-borne SARS-CoV-2-specific antibodies. Taken together, our study supports recommendations for uninterrupted breastfeeding subsequent to mRNA vaccination against COVID-19.

Guidance for the clinical management of infants born to mothers with suspected/confirmed COVID-19 in Singapore

In this paper, we provide guidance to clinicians who care for infants born to mothers with suspected/confirmed COVID-19 during this current pandemic. We reviewed available literature and international guidelines based on the following themes: delivery room management; infection control and prevention strategies; neonatal severe acute respiratory syndrome coronavirus 2 testing; breastfeeding and breastmilk feeding; rooming-in of mother-infant; respiratory support precautions; visiting procedures; de-isolation and discharge of infant; outpatient clinic attendance; transport of infant; and training of healthcare staff. This guidance for clinical care was proposed and contextualised for the local setting via consensus by members of this workgroup and was based on evidence available as of 31 July 2020, and may change as new evidence emerges.

Headache associated with refractive errors: Characteristics and risk factors

INTRODUCTION

The purpose of our work was to study the characteristics of Headache associated with refractive errors (HARE)¹, and to search for the correlation between headaches characteristics and some risk factors. We aimed also to assess the impact of these headaches on the quality of life of patients.

METHODS

A cross-sectional, retrospective, comparative study including 90 patients followed between August 2019 and January 2020. These patients were divided into two groups: Group 1 including patients presenting headaches due to uncorrected ametropia, and group 2 including control subjects. We studied HARE characteristics, the influence of certain risk factors (profession, triggers factors, characteristics of ametropia, and orthoptic abnormalities) on them, their evolution after one month of treatment, and their impact on patients' quality of life with the HIT-6 score.

RESULTS

Headaches due to ametropia were mainly chronic (20.9±15.76 months on average) progressive (100% of cases), daily (90% of cases) predominantly during the second half of the day (82% of cases). They were moderate (64% of cases), with a fronto-orbital topography in 52% of cases. Headaches were compression-type in 36% of cases (18 patients) and pressure-type in 64% (32 patients). The multivariate study retained prolonged screen working (P=0.013), combined ametropias (P=0.001), moderate hyperopia (P=0.01) and astigmatism (P=0.03) to be risk factors of HARE. Headaches induced a substantial to major impact on the quality of life in 68% (34 patients had a score greater than 55), the latter is significantly influenced by the presence of high myopia. After optical correction and orthoptic treatment, we noted an improvement in headache in 100% of cases. The multivariate analysis did not identify any independent factor that impact the evolution of headache at one month.

CONCLUSION

HARE may influence life quality; it needs an appropriate treatment based on risk factor management. A healthy lifestyle in addition to adequate refractive error correction is essential in children and, sometimes in adults. Oculomotor abnormalities treatment leads to improve long term results.

Breastfeeding in COVID-19: A Pragmatic Approach

The novel coronavirus disease 2019 (COVID-19) pandemic has resulted in changes to perinatal and neonatal care, concentrating on minimizing risks of transmission to the newborn and health care staff while ensuring medical care is not compromised for both mother and infant. Current recommendations on infant care and feeding when mother has COVID-19 ranges from mother-infant separation and avoidance of human milk feeding, to initiation of early skin-to-skin contact and direct breastfeeding. Health care providers fearing risks of severe acute respiratory syndrome-coronavirus-2 (SARS-CoV-2) maternal-infant transmission may veer toward restricted breastfeeding practices. We reviewed guidelines and published literature and propose three options for infant feeding depending on various scenarios. Option A involves direct breastfeeding with the infant being cared for by the mother or caregiver. In option B, the infant is cared for by another caregiver and receives mother's expressed milk. In the third option, the infant is not breastfed directly and does not receive mother's expressed milk. We recommend joint decision making by parents and the health care team. This decision is also flexible as situation changes. We also provide a framework for counseling mothers on these options using a visual aid and a corresponding structured training program for health care providers. Future research questions are also proposed. We conclude that evidence and knowledge about COVID-19 and breastfeeding are still evolving. Our options can provide a quick and flexible reference guide that can be adapted to local needs. KEY POINTS: · SARS-CoV-2 is unlikely transmitted via human milk.. · A shared decision making on infant feeding is the preferred approach.. · Mothers can safely breastfeed with appropriate infection control measures..

Restructuring Saudi Board in Restorative Dentistry (SBRD) curriculum using CanMEDS competency

OBJECTIVE

The purpose of this paper is to describe the process of adopting the Canadian Medical Education Directions for Specialists (CanMEDS) 2015 competency framework in a dental specialty program to reconstruct the Saudi Board in Restorative Dentistry (SBRD) curriculum and disseminate the lessons learned. Method and development process: The process of curriculum development was started with the selection of SBRD curriculum committee and review of CanMEDS framework. The Committee conducted needs assessment among the stakeholders and adopted CanMEDS 2015 competencies through a careful process. A modeled curriculum was developed after taking feedback, review of existing literature, and unique context of dentistry. Curriculum: Several unique features are incorporated. For example, milestones and continuum of learning are developed to enable residents develop competencies at different stages (transition to discipline, foundation of discipline, and core of discipline). Academic activities are restructured to encourage interactive, student-centered approaches, team work, intellectual curiosity, and scholarship. Learning outcomes are integrated throughout within several modules. Many formative assessment tools are adopted to promote learning and evaluate clinical skills.

CONCLUSIONS

This is the first published example of adopting CanMEDS competency framework in a dental specialty program. The success of developing SBRD curriculum has encouraged other dental specialties toward adopting CanMEDS 2015 frameworks for their own curricula.

Effect of a new longitudinal interprofessional geriatric medicine educational track on knowledge and attitude of medical students: a controlled cohort study

A new interprofessional geriatric medicine curriculum was recently introduced at a large undergraduate Asian medical school. A longitudinal controlled interventional cohort study was conducted to evaluate the effect of the new curriculum on the knowledge and attitudes of medical students. The medical students under the new curriculum formed the intervention cohort, and those under the former curriculum formed the control cohort. To test knowledge, the University of California at Los Angeles (UCLA) geriatrics knowledge test (GKT) was used in Year 2 and the University of Michigan GKT in Year 5. Geriatrics attitudes were evaluated using the UCLA geriatrics attitudes test in Years 2 and 5. Not surprisingly, geriatrics knowledge at the end of Year 5 of medical school was enhanced to a greater degree in the intervention cohort than the control cohort, although improvements in geriatrics attitudes in each cohort were of similar magnitude by the end of Year 5, suggesting that factors other than a formal geriatrics curriculum influenced the improvements in geriatrics attitudes. This article is one of few published on the effectiveness of geriatrics curricular innovations using validated knowledge and attitude outcomes in a longitudinal controlled study design and will be useful to other medical institutions seeking to improve the geriatrics knowledge and attitudes of their students.

What factors determine academic achievement in high achieving undergraduate medical students? A qualitative study

BACKGROUND

Medical students' academic achievement is affected by many factors such as motivational beliefs and emotions. Although students with high intellectual capacity are selected to study medicine, their academic performance varies widely.

OBJECTIVES

The aim of this study is to explore the high achieving students' perceptions of factors contributing to academic achievement.

MATERIALS AND METHODS

Focus group discussions (FGD) were carried out with 10 male and 9 female high achieving (scores more than 85% in all tests) students, from the second, third, fourth and fifth academic years. During the FGDs, the students were encouraged to reflect on their learning strategies and activities. The discussion was audio-recorded, transcribed and analysed qualitatively.

RESULTS

Factors influencing high academic achievement include: attendance to lectures, early revision, prioritization of learning needs, deep learning, learning in small groups, mind mapping, learning in skills lab, learning with patients, learning from mistakes, time management, and family support. Internal motivation and expected examination results are important drivers of high academic performance. Management of non-academic issues like sleep deprivation, homesickness, language barriers, and stress is also important for academic success.

CONCLUSION

Addressing these factors, which might be unique for a given student community, in a systematic manner would be helpful to improve students' performance.

A Comprehensive, Multi-modal Evaluation of the Assessment System of an Undergraduate Research Methodology Course: Translating Theory into Practice

OBJECTIVE

To evaluate assessment system of the 'Research Methodology Course' using utility criteria (i.e. validity, reliability, acceptability, educational impact, and cost-effectiveness). This study demonstrates comprehensive evaluation of assessment system and suggests a framework for similar courses.

METHODS

Qualitative and quantitative methods used for evaluation of the course assessment components (50 MCQ, 3 Short Answer Questions (SAQ) and research project) using the utility criteria. RESULTS of multiple evaluation methods for all the assessment components were collected and interpreted together to arrive at holistic judgments, rather than judgments based on individual methods or individual assessment.

RESULTS

Face validity, evaluated using a self-administered questionnaire (response rate-88.7%) disclosed that the students perceived that there was an imbalance in the contents covered by the assessment. This was confirmed by the assessment blueprint. Construct validity was affected by the low correlation between MCQ and SAQ scores (r=0.326). There was a higher correlation between the project and MCQ (r=0.466)/SAQ (r=0.463) scores. Construct validity was also affected by the presence of recall type of MCQs (70%; 35/50), item construction flaws and non-functioning distractors. High discriminating indices (>0.35) were found in MCQs with moderate difficulty indices (0.3-0.7). Reliability of the MCQs was 0.75 which could be improved up to 0.8 by increasing the number of MCQs to at least 70. A positive educational impact was found in the form of the research project assessment driving students to present/publish their work in conferences/peer reviewed journals. Cost per student to complete the course was US$164.50.

CONCLUSIONS

The multi-modal evaluation of an assessment system is feasible and provides thorough and diagnostic information. Utility of the assessment system could be further improved by modifying the psychometrically inappropriate assessment items.

The Knowledge-Attitude Dissociation in Geriatric Education: Can It be Overcome?

Introduction: A knowledge-attitude dissociation often exists in geriatrics where knowledge but not attitudes towards elderly patients improve with education. This study aims to determine whether a holistic education programme incorporating multiple educational strategies such as early exposure, ageing simulation and small group teaching results in improving geriatrics knowledge and attitudes among medical students. Materials and Methods: We administered the 18-item University of California Los Angeles (UCLA) Geriatric Knowledge Test (GKT) and the Singapore-modified 16-item UCLA Geriatric Attitudes Test (GAT) to 2nd year students of the old curriculum in 2009 (baseline reference cohort, n = 254), and before and after the new module to students of the new curriculum in 2010 (intervention cohort, n = 261), both at the same time of the year. Results: At baseline, between the baseline reference and intervention cohort, there was no difference in knowledge (UCLA-GKT Score: 31.6 vs 33.5, P = 0.207) but attitudes of the intervention group were worse than the baseline reference group (UCLA-GAT Score: 3.53 vs 3.43, P = 0.003). The new module improved both the geriatric knowledge (UCLA-GKT Score: 34.0 vs 46.0, P<0.001) and attitudes (UCLA-GAT Score: 3.43 vs 3.50, P <0.001) of the intervention cohort. Conclusion: A geriatric education module incorporating sound educational strategies improved both geriatric knowledge and attitudes among medical students. Key words: Asian medical school, Geriatrics attitudes, Geriatrics knowledge, Undergraduate medical student

The knowledge-attitude dissociation in geriatric education: can it be overcome?

INTRODUCTION

A knowledge-attitude dissociation often exists in geriatrics where knowledge but not attitudes towards elderly patients improve with education. This study aims to determine whether a holistic education programme incorporating multiple educational strategies such as early exposure, ageing simulation and small group teaching results in improving geriatrics knowledge and attitudes among medical students.

MATERIALS AND METHODS

We administered the 18-item University of California Los Angeles (UCLA) Geriatric Knowledge Test (GKT) and the Singapore-modified 16-item UCLA Geriatric Attitudes Test (GAT) to 2nd year students of the old curriculum in 2009 (baseline reference cohort, n = 254), and before and after the new module to students of the new curriculum in 2010 (intervention cohort, n = 261), both at the same time of the year.

RESULTS

At baseline, between the baseline reference and intervention cohort, there was no difference in knowledge (UCLA-GKT Score: 31.6 vs 33.5, P = 0.207) but attitudes of the intervention group were worse than the baseline reference group (UCLA-GAT Score: 3.53 vs 3.43, P = 0.003). The new module improved both the geriatric knowledge (UCLA-GKT Score: 34.0 vs 46.0, P <0.001) and attitudes (UCLA-GAT Score: 3.43 vs 3.50, P <0.001) of the intervention cohort.

CONCLUSION

A geriatric education module incorporating sound educational strategies improved both geriatric knowledge and attitudes among medical students.

Does the introduction of a third examiner and global marking improve the generalisability of the surgical long case?

INTRODUCTION

Planning a high-stake clinical examination requires the evaluation of several psychometric and logistical variables. The authors conducted generalisability and decision studies to answer the following research questions in the context of the surgical long case: (1) Does the addition of a third examiner have any added benefit, vis-à-vis reliability, to the examination? (2) Is global marking more reliable than an itemised marking template? (3) What would be the impact on reliability if there was a reduction in the number of examinees that each panel of examiners is required to assess?

METHODS

A third examiner and global marking were introduced. Separate generalisability and decision studies were carried out for both the two- and three-examiner models as well as for itemised and global scores.

RESULTS

The introduction of a third examiner resulted in a modest gain of reliability by 0.05-0.07. Gain in reliability was higher when each candidate was allowed to undertake a higher number of clinical cases. Both the global and itemised scores provided equivalent reliability (generalisability coefficient 0.74-0.89).

CONCLUSION

Our results showed that only a modest improvement in reliability of the surgical long case is achieved through the introduction of an additional examiner. Although the reliability of global scoring and the itemised marking template was comparable, the latter may provide opportunities for individualised feedback to examinees.

Technology-enabled assessment of health professions education: consensus statement and recommendations from the Ottawa 2010 Conference

The uptake of information and communication technologies (ICTs) in health professions education can have far-reaching consequences on assessment. The medical education community still needs to develop a deeper understanding of how technology can underpin and extend assessment practices. This article was developed by the 2010 Ottawa Conference Consensus Group on technology-enabled assessment to guide practitioners and researchers working in this area. This article highlights the changing nature of ICTs in assessment, the importance of aligning technology-enabled assessment with local context and needs, the need for better evidence to support use of technologies in health profession education assessment, and a number of challenges, particularly validity threats, that need to be addressed while incorporating technology in assessment. Our recommendations are intended for all practitioners across health professional education. Recommendations include adhering to principles of good assessment, the need for developing coherent institutional policy, using technologies to broaden the competencies to be assessed, linking patient-outcome data to assessment of practitioner performance, and capitalizing on technologies for the management of the entire life-cycle of assessment.

Head and neck follicular dendritic cell sarcoma: disease associations and treatment review

Currently, of less than 50 cases of head and neck follicular dendritic cell (FDC) sarcoma reported in the literature, 5 have been found to occur in the background of Castleman disease. We report another case of head and neck FDC sarcoma with emphasise on its associated lesions and review the outcome of treatment from the existing cases in the literature.

Relevance of the Flexner Report to contemporary medical education in South Asia

A century after the publication of Medical Education in the United States and Canada: A Report to the Carnegie Foundation for the Advancement of Teaching (the Flexner Report), the quality of medical education in much of Asia is threatened by weak regulation, inadequate public funding, and explosive growth of private medical schools. Competition for students' fees and an ineffectual accreditation process have resulted in questionable admission practices, stagnant curricula, antiquated learning methods, and dubious assessment practices. The authors' purpose is to explore the relevance of Flexner's observations, as detailed in his report, to contemporary medical education in South Asia, to analyze the consequences of growth, and to recommend pragmatic changes. Major drivers for growth are the supply-demand mismatch for medical school positions, weak governmental regulation, private sector participation, and corruption. The consequences are urban-centric growth, shortage of qualified faculty, commercialization of postgraduate education, untenable assessment practices, emphasis on rote learning, and inadequate clinical exposure. Recommendations include strengthening accreditation standards and processes possibly by introducing regional or national student assessment, developing defensible student assessment systems, recognizing health profession education as a field of scholarship, and creating a tiered approach to faculty development in education. The relevance of Flexner's recommendations to the current status of medical education in South Asia is striking, in terms of both the progressive nature of his thinking in 1910 and the need to improve medical education in Asia today. In a highly connected world, the improvement of Asian medical education will have a global impact.

Motivation, study habits, and expectations of medical students in Singapore

OBJECTIVES

To determine the motivation and incentives in education, learning experience and teaching techniques, and expectations about future careers among medical students from a multi-ethnic Asian country.

METHODS

Pre-validated questionnaire-based survey with stratified random sampling among medical students. The questionnaire combined qualitative responses with semi-quantitative measures of available alternatives.

RESULTS

The response rate was 83.1%. The most important factor for pursuing university study was 'prospect of finding an interesting challenging job' (rank 1-75%). Family made a significant contribution in decision making. Given the chance, a majority (67.2%) of respondents would prefer to study overseas. The main deterring factors were cost (67.7%), distance from home (28%), and local opportunity for post-graduation (23.4%). Despite their inclination of study overseas, the majority (73.9%) of the respondents indicated they were either very satisfied or satisfied with their current choice of university study. Only 20% of students were comfortable in asking questions in classroom as asking questions was deemed 'too risky' and 'unnecessary to get better grades'. Students adopted strategies related to assessment and competition to monitor their study. Senior students reported university education as less relevant to their future careers as compared to junior students (p = 0.002).

CONCLUSIONS

Students' learning behaviour is determined by complex factors such as educational incentives, learning support, assessment and competition. Among several external factors, family, job prospects and expectations about the future play a critical role in education.

A multi-institutional survey on faculty development needs, priorities and preferences in medical education in an Asian medical school

BACKGROUND

Faculty development in medical education is crucial for maintaining academic vitality. The authors conducted a needs assessment survey in Singapore to determine the educational needs and priorities of clinical faculty.

METHODS

This study implemented a questionnaire-based, anonymous, multi-institutional survey with stratified random sampling. Each question was anchored with two statements on a 9-point scale. Respondents were asked to determine their current knowledge and the knowledge they would need in future.

RESULTS

The response rate was 81.9%. Overall, the participants' current knowledge was rated either "modest" (scale 4-6) or "substantial" (scale 7-9), irrespective of teaching experience. Participants reported higher knowledge in areas related to teaching and modest knowledge in educational concepts and assessment. They reported a need for higher knowledge in most areas to function well as a teacher.

CONCLUSION

The need for faculty development is universal and independent of teaching experience in this group. Teaching faculty from the institutes studied understood the need for improved knowledge in pedagogical knowledge.

Head injury with temporal bone fracture: one year review of case incidence, causes, clinical features and outcome

To investigate the case incidence, causes, clinical profile and outcome of temporal bone fracture complicating head trauma. A 1-year (2005) retrospective study of head injured patients presented to the Emergency Department, Hospital Tengku Ampuan Afzan, Kuantan, Pahang, Malaysia. Gender distribution, cause of injury, radiological findings and otorhinolaryngological clinical presentations were analyzed. Of 1309 patients, 61 patients were diagnosed to have temporal bone fracture (4.7%). Majority of cases were caused by motor vehicle accident (85.9%) and were predominantly male (88.5%). The right temporal bone was more frequently fractured (62.3%). Most (88.5%) were petro-mastoid fractures. Sixty-seven percent of the petrous fractures were longitudinal type. Clinical presentations mostly reported were blood rhinorrhea (36%) and blood otorrhea (32.7%). Other clinical presentations were hearing loss (9.8%), cranial nerve palsy (8.2%), cerebrospinal fluid oto-rhinorrhea (8.2%) and labyrinth concussion (6.5%). Four out of five cranial nerve palsies were facial nerve. Out of the 61 cases, 16 (26.2%) had no clinical presentation at the time of Emergency Department consultation. Thirteen (21.3%) died due to severe head injury. The case incidence of temporal bone fracture in head injured patients in our centre is 4.7%. The petro-mastoid type fracture predominates. Proper early diagnosis and management minimize complications.

Paediatric airway reconstruction: a preliminary study

To set the foundation for developing a centre for airway reconstruction, we performed a retrospective database review of patients operated at a tertiary-care university hospital. Over the past 3-year period from 2004 onwards, five paediatric cases of airway reconstruction procedures were performed. All cases had a two stages laryngotracheal reconstruction (TSLTR) for laryngotracheal stenosis (LTS). All patients were children below 15 years and the mean age was 9 years. Only one patient had a Grade IV Myer-Cotton stenosis, the rest all had Grade III stenosis. Three out of four of the Grade III stenosis patients were successfully decannulated within one year, the other one died of causes unrelated to LTS. The grade IV patient was still under followup and surgery was done only recently. This paper highlights the complexity of managing LTS in the paediatric age group and recommends the use of LTR with rib graft as a choice for the management of LTS.

Medical education in Bangladesh

Bangladesh shares many socio-cultural, financial, and health issues typical of developing countries. Despite some encouraging developments in health measures at grass-roots level, medical education in Bangladesh faces many challenges. This article provides a snapshot of the current situation of undergraduate and post-graduate medical education with particular emphasis on pedagogical issues, highlighting challenges faced and suggesting an immediate five-point action plan.

Attitudes, Practice and Educational Preferences Towards Evidence-Based Medicine among Physicians in a Large Teaching Hospital

Evidence-based medicine (EBM) is an emerging must-know topic for today's physicians. The present literature is inadequate in identifying the attitudes, practice, and educational needs and preferred interventions of EBM. The objectives of this survey were to identify a) the attitude toward and practice of EBM among physicians, b) perceived benefits of EBM in daily practice, c) barriers to EBM practice, and d) preferred educational interventions.

METHODS

This was a questionnaire-based cross-sectional survey of physicians in a single large teaching hospital.

RESULTS

Overall, 56% of the physician respondents described the attitude towards EBM in their institution as positive. A similar number of physicians also reported the attitude of their colleagues towards EBM as favourable. 67% of the physicians believed EBM was useful in daily management of patients. In contrast, only 45% of the physicians actually practiced EBM in their daily patient management. The factors that discouraged them from actual practice include a lack of time, lack of exposure to EBM during their undergraduate curriculum, lack of endorsement, and fear of criticism by seniors. Physicians preferred less time consuming and less rigorous educational interventions such as clinical practice guidelines, journal club, and case review and discussion for teaching and learning EBM.

INTERPRETATION

There are disconnects between belief and actual practice and between preferred and ideal educational interventions of EBM among physicians surveyed.