Introduction: Sleep abnormalities, including narcolepsy and cataplexy, are a common feature of Prader-Willi syndrome. Long-term treatment with the central nervous system stimulant modafinil has not been reported. In this case report we present a longitudinal perspective of sleep abnormalities in a nine-year-old Caucasian girl with Prader-Willi syndrome from age two to age nine, and detail the response to treatment with the central nervous system stimulant modafinil. Case presentation: Our patient presented at two years of age with hypersomnia and narcoleptic episodes with cataplectic features. Initial polysomnograph testing revealed adequate sleep efficiency, but increased sleep fragmentation especially during rapid eye movement sleep. The narcoleptic episodes continued and a repeat polysomnograph at age five years confirmed features consistent with narcolepsy. Further sleep studies at six years, including a multiple sleep latency test, demonstrated signs of excessive daytime sleepiness. Treatment with modafinil was initiated at age seven years six months due to persistent hypersomnia and narcoleptic symptoms. Two polysomnograph studies were performed following treatment with modafinil, at age eight years six months and nine years three months. These studies showed excellent sleep efficiency and improvement of rapid eye movement sleep parameters, supporting the beneficial effects of long-term modafinil therapy. Conclusions: Long-term modafinil therapy may ameliorate the sleep disturbances of Prader-Willi syndrome and should be the focus of future clinical trials.

Background: Graduate medical education is refocusing on the reconciliation process with Indigenous peoples and integrating Indigenous healing practices, cultural humility training, and courses on Indigenous health issues in their curricula. Physicians and all health care workers must be able to recognize, respect, and address the distinct health needs of all Indigenous peoples. Objective: The aim of this scoping review was to explore and describe what exists in the current literature on the impact and challenges associated with Indigenous curricula developed for resident physicians. Methods: The search was conducted using 9 bibliographic databases from inception until April 19, 2021. Two reviewers independently screened for inclusion using Covidence. Three reviewers extracted data and all 3 checked for completeness and accuracy. Results: Eleven reports were included. Our included reports consisted of qualitative research (n=2), commentaries (n=1), special articles (n=3), systematic reviews (n=1), innovation reports (n=1), published abstracts (n=1), and program evaluation papers (n=2). Findings are presented by 3 themes: (1) Misunderstandings and cultural bias toward Indigenous people; (2) Increasing community-driven Indigenous partnerships to create a safe environment; and (3) Challenges in implementing Indigenous health curricula. Conclusions: Themes identified related to Indigenous involvement, culturally competent care, common misconceptions about Indigenous peoples, as well as challenges and barriers to implementing Indigenous curricula for residency programs. A collaborative approach involving stakeholders with training in the community is a viable path forward. But comprehensive program evaluation, a source of stable funding, and further research focusing on effective Indigenous curricula for residents are needed.

Objectives: An antimicrobial stewardship intervention was implemented for pediatric medicine units using an in-person rounds-based approach to provide stewardship recommendations and education from an antimicrobial stewardship physician and antimicrobial stewardship pharmacist. Design, Setting, Participants, and Methods: In this exploratory qualitative study, purposeful sampling was used to recruit participants for individual interviews at a tertiary- and quaternary-care referral center. Pediatricians and residents who attended ≥1 stewardship round were included. A semistructured interview guide was created focusing on perceptions of antimicrobial stewardship, personal experiences at stewardship rounds, and perceived impacts on patient care. Using a constant comparative analysis approach, codes were developed and collapsed into themes. Results: Overall, 8 pediatricians and 10 residents completed interviews. Qualitative analysis yielded 3 themes: insights into clinical reasoning, opportunity for growth and learning, and establishing and exploring professional relationships. The handshake-rounds approach encouraged participants to critically evaluate antimicrobial choices and to engage in discussion with the antimicrobial stewardship team. Participants felt validated at stewardship rounds and gained confidence prescribing antimicrobials. Face-to-face interaction reduced reluctance for some participants to consult infectious disease (ID) service; however, others worried that physicians may avoid ID consultation because of stewardship rounds. Conclusions: Participants found stewardship rounds to be an effective strategy for education and development of clinical reasoning skills for optimal antimicrobial prescribing—choosing wisely or choosing rightly. The effects of stewardship rounds on timing and frequency of ID consultation are interesting. Further research into important patient outcomes and consultation practices are needed locally, but our experiences may help others to reflect on the power of conversation and relationships in antimicrobial stewardship.

Background: Guidelines on Brief Resolved Unexplained Event (BRUE) only provide recommendations for infants categorized at lower risk. However, most infants fall into the higher‐risk category, leaving management decisions to individual clinicians and contributing to variation in care. Objectives: Describe interhospital variation in BRUE management and determine whether higher resource utilization improves detection of serious underlying diagnoses. Methods: This multicenter observational cohort (2017–2021) included infants (< 12 months) with BRUE at eight Canadian hospitals. We recorded admission, and use of electrocardiograms (ECG), electroencephalograms (EEG), antibiotic and anti‐reflux medications, and subspecialty consultations. Multivariable median regression evaluated the association between tests/interventions and length of stay (LOS), and logistic regression assessed whether site‐level resource use correlated with serious underlying diagnoses detection. Results: Of 758 infants (92% higher‐risk), we noted variation in admission rates (32%–76%, p < .001), ICU admissions (0%–20%, p < .001), median LOS (0.8–2.0 days, p < .001), ECG (24%–78%, p < .001), EEG (8%–29%, p = .001), and anti‐reflux medication (0%–21%, p < .001). Five percent had a serious underlying diagnosis, with no significant site differences (0%–8%, p = .49). Median regression showed EEG (19.9 h, 95% CI: 6.8–33.0, p = .03), empiric antibiotics (15.8 h, 95% CI: 4.7–26.9, p = .03), and subspecialty consultation (17.0 h, 95% CI: 10.8–23.2, p < .001) were associated with longer LOS. Higher resource use did not increase detection of serious underlying diagnoses. Conclusions: Substantial variation exists in BRUE management, associated with prolonged LOS. Higher admission and testing were not associated with increased detection of serious underlying diagnoses. These findings highlight the need for standardized care approaches.