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Summary of hands-on practical exercise: supervised evaluation of children.

Children selection: Children evaluation was performed following public announcement of the availability of supervised cardiac evaluation of children during the PCIP course, both among hotel personnel as well as among parents of a geographically remotely located primary school  in South Crete (3rd grade school children only). Furthermore, selected pediatric cardiology outpatients were evaluated in the outpatient clinic of University hospital of Heraklion. The coordinator represents the only academic pediatric cardiology facility in the region of Crete, has a permission for screening 3rd grade school children in the region of Crete by the Greek Ministry of Health, while University Hospital of Heraklion Scientific Committee approved the use of pediatric cardiology outpatient clinic for the purposes of the PCIP course.

The evaluation of hotel personnel children was performed in the hotel (in specifically transformed as examination room area of the hotel) while school children were evaluated in two regional health stations of South Crete with participant teachers and students divided respectively into two working groups (for Xarakas and Pirgos health stations). The hotel administration, school director and teachers, local authorities and health station administration and personnel enthusiastically supported this initiative, by distributing relevant informative material, organizing PCIP participant transfer to the remote  health station and providing all possible means and support.

PCIP participants attended also an outpatient pediatric cardiology clinic in University Hospital of Heraklion as well, where selected by coordinator outpatients were presented to students and discussed by all teachers. All parents of participant children provided a signed informed consent for the participation of their children in the hands-on supervised practical exercise, accompanied their children throught all examinations and in cases where further testing was considered as appropriate, we contacted families and arranged that all children would be evaluated in the University Hospital within 1 month following their initial evaluation.

A total of 60 children were evaluated during PCIP 2013 course. These included 12 hotel personnel children (3 female, 9 male, mean age 6.4 yrs, range 2-10 yrs), 43 school children (25 female, 18 male, mean age 8.7 yrs) and 7 pediatric cardiology outpatients (including 2 antenatal-fetal evaluations).

Hands-on practice experience: Of the total group of 60 children, 5 had a previous diagnosed heart disease and 1 further child was detected with (minor) congenital heart disease during hands-on practical exercise. Students were provided the chance to evaluate clinical, ECG and echo findings (where applicable) of children and discuss their findings with supervising teachers. We have devided students into small groups (groups of no more than 5 students supervised by a single professor each), to ensure that each student will have the chance to evaluate sufficient number of children, without causing any discomfort or stress to children and families through repeated evaluations by large number of students.

Clinical auscultation practice: 15 children had a detectable heart murmur (interpreted as innocent in 7 and abnormal  in 8 cases-included was the child who was diagnosed with minor heart defect), 3 children had additional abnormal auscultatory findings.

ECG interpretation practice:  13 children had abnormalities in their electrocardiogram, of them 5 were considered as possible normal variants and 8 as definitely abnormal ECG types.

ECHO interpretation practice:  12 children received a complete echocardiographic evaluation, either by one of the 4 portable echocardiographic systems provided exclusively for the PCIP course purposes by medical imaging industry, or by the echocardiographic system available in the academic pediatric cardiology outpatient clinic of the coordinator. Except of the 5 pediatric cardiology outpatients, 7 further children (4 hotel personnel, 3 school children) and 2 fetuses were evaluated. Abnormal echocardiographic findings were present in 6 cases (5 pediatric cardiology outpatients and 1 school child) and in 1 fetal evaluation.

Outcomes of evaluation: Among 12 hotel personnel children, 4 received additional complete echocardiographic evaluation, which documented the spontaneous closure of a previously known ventricular septal defect in one, and was normal in other 3 children with abnormal electrocardiographic findings (n=3) or unspecific heart murmur (n=1). In one child with adiposity dietary and life style modification instructions were provided and follow up was recommending in a further child with palpitations. Regarding primary school children, 1 having abnormal auscultatory findings and 2 having borederline abnormal auscultatory findings were offered further echocardiographic evaluation (wich was positive for mild congenital heart defect-ventricular septal defect in the child with abnormal auscultation, the remaining 2 were normal). 13 children were given dietary instructions due to detection of adiposity, 2 were asked for repeat of ECG along with 24 hours ECG recording due to arrhythmia, 6 were asked to repeat ECG within 1 year for unspecific abnormalities , and 2 were referred for further pediatric evaluation for non-cardiac indications ( pulmonology) based on history information. Finally, selected pediatric cardiology outpatients, following their presentation to students, participant teachers discussed their findings and came into a consensus regarding their best treatment approach.