Respiratory Syncytial Virus in a Child With Dravet Syndrome: A Case Report.

The objective of this case report is to describe and document a case of respiratory syncytial virus (RSV) in a pediatric patient with Dravet syndrome (DS), also known as severe myoclonic epilepsy of infancy. Febrile seizures are often a complication in a patient with DS and can lead to status epilepticus, necessitating measures to prevent triggers such as fever, electrolyte imbalance, or dehydration. An increased awareness and understanding of DS can facilitate the identification of warning signs. A two-year-old female with a past medical history of DS with focal and generalized features presented to the pediatric emergency department (ED) with a five-day history of cough, fever, and decreased oral intake. The patient's parents accompanied her and expressed concerns regarding the risk of seizures associated with a rise in body temperature, as they had been alternating between acetaminophen and ibuprofen to manage her fever with a maximum recorded temperature of 101.5℉. She exhibited signs of increased work of breathing, necessitating the administration of supplemental oxygen via nasal cannula. Blood samples were obtained and resulted in the development of metabolic acidosis. A respiratory panel confirmed the presence of an RSV infection, promoting the administration of breathing treatment with albuterol and ipratropium bromide. The patient was admitted for dehydration and was started on ½ normal saline/potassium chloride 20 mEq at 40 mL/hr. Additionally, her home medication regimen was resumed to minimize the risk of seizures. Given the patient's complications and increased risk of seizure, she was transferred to higher-level care where her status improved after the placement of a percutaneous endoscopic gastrostomy (PEG). This case underscores the complexities involved in managing patients with DS, particularly when complicated by respiratory illness and electrolyte imbalances that can lower the seizure threshold. This patient received a combination of diet and medications to prevent seizures, as well as allow for recovery and correction of the underlying metabolic acidosis. The transfer to a higher level of care in this case was necessary to allow for the specialized resources and expertise needed to handle this case.

Necrotizing Enterocolitis in an Infant With a History of Twin-Twin Transfusion Syndrome: A Case Report.

This case report describes necrotizing enterocolitis (NEC) in an infant with a history of twin-twin transfusion syndrome (TTTS). TTTS is a volume imbalance where the anastomosis at the vascular equator between the two placentae shifts from the donor to the recipient twin. This causes a higher risk for NEC, a marked inflammation caused by bacterial infection into the intestinal wall, from prematurity and intestinal hypoperfusion. Complications include sepsis, bowel necrosis, perforation, peritonitis, and death. NEC is a leading cause of morbidity in preterm infants. A 3-month-old female with a history of TTTS and prematurity presented with her mother to the pediatric emergency department (ED) for bloody diarrhea, emesis, lack of appetite, and lethargy for 4 days. The pediatrician changed the formula due to a possible milk allergy, however, she continued to have bloody diarrhea. Over the 2 days, the patient had nonbilious and non-bloody emesis and couldn't tolerate oral intake. In the ED, labs showed neutropenia and sepsis. She had a positive fecal occult blood test (FOBT) and an abdominal x-ray that revealed dilated loops of bowel and pneumatosis intestinalis. She was started on intravenous (IV) fluids for maintenance of hydration. She was started on broad-spectrum antibiotics including intravenous (IV) vancomycin and meropenem, and had her feedings temporarily stopped. The patient was transferred to the pediatric intensive care unit (PICU) at a tertiary care/children's hospital that evening where she had a laparotomy performed to resect the diseased intestine. She was discharged 10 days after the surgery for home recovery with clinical follow-up.

Transcranial Magnetic Stimulation in Bipolar II Disorder Treatment: A Case Report.

The objective of this case report is to describe and document the use of transcranial magnetic stimulation (TMS) to aid in the treatment of bipolar II disorder. A 35-year-old male with a past medical history of attention-deficit/hyperactivity disorder (ADHD), post-traumatic stress disorder (PTSD), severe depression, and bipolar II disorder was presented to an outpatient psychiatric clinic 1.5 years after his initial TMS treatment for TMS maintenance therapy. He reported feeling depressed, brain fogginess, loss of concentration, fatigue, and constant changes in moods. He had tried multiple antidepressants and antipsychotics, seen several therapists, and underwent electroconvulsive therapy in 2014 with no improvement. In August 2021, he underwent the standard TMS protocol with 36 treatments and noticed significant improvement in his symptoms. He followed up with his psychiatrist who placed him on quetiapine 400 mg, lurasidone 120 mg, topiramate 100 mg, Adderall 20 mg, Wellbutrin 150 mg, propranolol 20 mg, and Klonopin 0.5 mg for management. However, after starting these medications, he noticed a loss of concentration, not being able to think straight, fatigue, depression, and a change in moods. In January 2023, the patient underwent maintenance TMS treatment with theta bursts (TBS). The treatment protocol consisted of 10 sessions for 3 ½ minutes each, 20 trains, 10 bursts, and eight seconds between intervals. He completed his treatment and reported feeling great and like himself again. Two weeks following treatment, he reported that his brain fog had resolved, hypomanic episodes had lessened, and depressive moods had been occurring less often. Due to improvement, topiramate and lurasidone were discontinued and the patient will continue with monthly follow-ups to monitor his progress. TMS appears to be a promising treatment option for bipolar disorder.

The Use of Mock Standardized/Simulated Patient Encounters in Facilitating Development of Clinical Competence in Medical Students.

Background Standardized patient (SP) encounters are used in medical school to mimic clinical practice by exposing students to possible clinical situations they may encounter in future practice. SP includes trained individuals who portray the roles of patients to help medical students practice recording medical histories, physical exam skills, communication skills, and typing a subjective, objective, assessment and plan (SOAP) note. The goal of SP is to prepare medical students adequately during their didactic years before beginning clerkships. SP encounters have become standard in medical school curriculums, but the option for a mock SP encounter has not.  Methods In this study, a total of 34 participants completed an eight-question survey before a mock SP experience and after their graded SP encounters to assess the students' confidence levels and preparedness. Each question addressed a different aspect of the student's satisfaction and attitude regarding the SP encounters. The answers were measured on a Likert scale from 1 (not prepared) to 5 (very prepared). The central tendency (mean) was analyzed using a T-test with Welch's method. The standard deviation was analyzed using Bonett's test. A Cronbach's alpha was used to show the reliability of the survey used. Results The first four questions addressed the student's satisfaction with their mock SP experience. The mean student satisfaction with being able to ask questions to improve their knowledge and understanding improved, with a p-value of < 0.001. Student satisfaction with having the opportunity to record a patient's history improved, with a p-value of < 0.001. The overall satisfaction with having a chance to practice physical exam skills improved, with a p-value of < 0.001. Mean student satisfaction with practicing treatment and counseling of patients improved, with a p-value of <0.001. The final four questions addressed the students' attitudes regarding their experience. The mean confidence of students improved, with a p-value of <0.001. Students also reported an improved attitude towards the feedback they received, with a p-value of <0.001. The final two questions did not show a statistically significant difference in answers. Students rated the final two questions equally before and after the mock SP experience, with p-values > 0.05. These questions addressed whether mock SP encounters would be beneficial and asked if they wanted additional mock simulation opportunities built into the curriculum. Conclusions The students showed improved confidence, attitudes, and satisfaction surrounding standardized patient encounters. The results supported the hypothesis that there would be a difference between the responses before and after the SP encounter. The questionnaire showed that the students reported subjective changes in their competence following the encounter.