Perceived educational value and enjoyment of a rural clinical rotation for medical students.

INTRODUCTION: It is well-recognised that medical students whose training exposure is largely limited to tertiary-level training hospitals may be inappropriately equipped to deal with the most relevant health issues affecting rural communities. This article evaluated the perceived educational value of a 2 week clinical rotation undertaken by senior undergraduate medical students at rural district hospitals and health care centers in the Western Cape Province, South Africa. METHODS: Students completed a daily log diary to provide an overview of time spent on specific academic activities, ranking the educational and enjoyment value of each activity. At the end of the 2 week rotation students completed an open-ended questionnaire capturing the main positive and negative aspects of their experience, followed by focus group discussions with a randomly selected subgroup. In addition, a formal feedback seminar was arranged with the academic supervisors at each of the training sites to triangulate the information received and to document their perspective. RESULTS: Thirty-seven students consented to study participation and 25 (68%) adequately completed the log diaries and questionnaires, rating the following activities as most educational: 'assisting in theatre', 'teaching by doctor', 'seeing patients in clinic/health centre/OPD' and 'mobile clinic excursions'. The rural experience allowed practical application of their theoretical knowledge, which improved their levels of confidence and enjoyment. The most enjoyed activities were: 'mobile clinic excursions', 'performing medical procedures' and 'teaching by doctor'. The students were critical of some aspects: (i) the rural rotation was not structured efficiently; (ii) compulsory written reports and additional projects prevented them from maximizing the rural experience; and (iii) a time period of 2 weeks was felt to be too short for optimum benefit from the rotation. CONCLUSION: The feedback obtained from this log diary study demonstrates that well-functioning rural health care centers provide excellent opportunities for students to develop the most relevant practical skills required of generalist doctors working in resource-limited settings. In addition to a more efficiently structured rural program, students requested an increase in the length of the rotation and a reduction in the written academic workload.

Illuminating the interrelated immune and endocrine adaptations after multiple exposures to short immobilization stress by in vivo blocking of IL-6.

Intermittent psychological stress was induced in adult rats by 2 h/day of immobilization stress for 4 days, with or without blocking the function of IL-6 by using an anti-IL-6 antibody. Basal concentrations of serum corticosterone, IL-1beta, IL-6, and TNF-alpha were assessed 24 h after the last intervention, as were levels of glucocorticoid receptors (GR) and activities of glucocorticoid-inducible enzymes (tyrosine aminotransferase and glutamine synthetase) in muscle and liver. Whole blood cultures were used to assess both spontaneous and LPS-induced reactivity of peripheral blood mononuclear cells. Stress increased corticosterone concentration in a manner partially modulated by IL-6. Serum IL-1beta concentration was downregulated during stress when IL-6 was blocked (P < 0.01). LPS-induced IL-6 secretion by peripheral blood mononuclear cells in vitro correlated positively with serum IL-1beta concentration in antibody-treated groups, independently of stress (R = 0.70 in nonstressed and R = 0.78 in stressed rats; both P < 0.05), whereas serum corticosterone concentration correlated positively with LPS-induced secretion of IL-6 only in control rats (R = 0.66; P < 0.05). Reductions in liver GR levels indicated independent effects of stress (34.5%) and anti-IL-6 antibody (16.7%) and additive effects for both (62.5%). Similar results are reported for vastus muscle. Conversely, stress increased tyrosine aminotransferase and glutamine synthetase activities in muscle and liver with a significant (P < 0.05) effect of anti-IL-6 antibody only seen in stressed livers. In conclusion, IL-6 plays a role in maintaining circulating IL-1beta concentration after multiple exposures to stress, thus promoting a continued elevation of corticosterone release; in peripheral tissues, IL-6 antagonizes the effects of glucocorticoids, especially at the level of GR concentration.

Cockroach and other inhalant allergies in infantile asthma.

BACKGROUND: Infantile asthma is commonly thought to be caused by viral respiratory infections and exposure to second-hand cigarette smoke. Allergy has not been felt to be a major cause of infantile asthma and infants and small children are not commonly skin tested. OBJECTIVE: To determine the frequency of skin test reactivity in asthmatic children less than 3 years of age. METHODS: We evaluated 196 (50 female/146 male) children with infantile asthma for allergy. Infantile asthma was defined as three or more episodes of wheezing in a child less than 3 years of age. A careful environmental history was obtained on all children. All were skin tested to alternaria, cat, dog, cockroach, and house dust mites (HDM) extracts using the prick technique with the Greer Dermapik. RESULTS: Forty-five percent of the infants and children tested had at least one positive skin test. 51/196 (26%) of the children were skin test positive to cockroach, 17.3% to HDM, 13.8% to cat, 6.6% to alternaria, and 6.1% positive to dog. For the 49 children who were less than 1 year of age, 28.5% were positive to cockroach, 10.2% to HDM, 10.2% to cats, 4% to alternaria, and 0% to dog. CONCLUSIONS: Allergy to cockroach and other indoor allergens may be a significant contributor to infantile asthma in a rural setting. Skin testing children with infantile asthma may provide useful information for institution of environmental controls measures in the child's home.

Tourette's syndrome mimicking asthma.

Tourette's syndrome is a neurological disorder consisting of chronic motor tics and involuntary vocalizations. Some of these vocalizations include coughing, grunting, and wheezing. We report two adolescents with a history of chronic coughing who presented for further evaluation of previously diagnosed asthma. A careful history suggested that Tourette's syndrome might be responsible for the patients' symptoms. Neurology evaluation confirmed the correct diagnosis of Tourette's syndrome for both patients. Treatment specific for this disease led to ablation of all symptoms. A history of repetitive coughing in adolescents may be the presenting symptom of Tourette's syndrome, thereby mimicking cough-equivalent asthma.

Renal transplantation in a patient with common variable immunodeficiency.

A 15-year-old girl developed end-stage renal disease requiring renal transplantation. Posttransplantation immunosuppression therapy consisted of antithymocyte globulin, glucocorticosteroids, cyclosporine A, and azathioprine. The patient's clinical course after transplantation was complicated by several episodes of graft rejection, chronic anemia, oral candidiasis, and numerous infections of the sinopulmonary tract that were recalcitrant to antibiotics and surgical intervention. An immunologic evaluation showed marked immune abnormalities beyond that expected by the transplant immunosuppression. Examination of serum samples taken before the transplant confirmed a diagnosis of common variable immunodeficiency. The difficulties of managing posttransplantation immunosuppression in a patient with a primary immunodeficiency are discussed. Patients with end-stage renal disease and a history of recurrent sinopulmonary infections may require immunologic screening before renal transplantation.

Idiopathic anaphylaxis in children.

BACKGROUND: Idiopathic anaphylaxis is a disease where no identifiable antigen or disease initiates an anaphylactoid reaction. Unlike classic IgE antibody-mediated anaphylaxis, severe idiopathic anaphylaxis is treatable with corticosteroids. To date, only 22 pediatric cases from one referral center have been reported. OBJECTIVE: To describe the characteristics of children with idiopathic anaphylaxis METHODS: A retrospective review of medical records for children presenting to the pediatric allergy clinic with the diagnosis of idiopathic anaphylaxis was performed. RESULTS: The review identified eight children with idiopathic anaphylaxis. All eight patients had a cutaneous finding of either urticaria, angioedema, or generalized flushing. Six of the eight patients were noted to have wheezing or angioedema of the airway causing respiratory difficulties. Diarrhea was noted among six patients. Many of the children clearly had life threatening events. Response to appropriate therapy was generally good. CONCLUSIONS: Pediatric idiopathic anaphylaxis can present at any age. It may be that many pediatric cases are assumed to be anaphylaxis due to some unknown antigen, and the correct diagnosis is never appreciated. It is important to recognize this disease in children so that it may be appropriately treated, because its specific therapeutic regimen has been shown to prevent the potentially fatal consequences of this disease.

Laryngeal papilloma presenting as steroid-dependent asthma in a 3-year-old child without recurrent stridor.

Upper airway obstruction is well described as a cause of apparent asthma. However, it can be very difficult to diagnose in young children. This 3-year-old male presented with a 1-year history of severe recurrent wheezing with six emergency room visits in the previous 5 months. Cromolyn, inhaled corticosteroids, and frequent predinisolone bursts had not controlled the wheezing. There was no history of barky cough, croup, or stridor. His physical examination was notable for marked nasal obstruction. At initial presentation, his lungs were normal with no wheezing or stridor. Soft tissue neck X-ray films suggested the presence of a subglottic mass. A large solitary papilloma was found on bronchoscopy. After surgical removal, there was no further wheezing noted by either the parents or his physicians. Laryngeal papillomatosis may mimic asthma in the absence of symptoms of hoarseness, croup, or stridor. It should be particularly considered in 2 to 4-year-old children with recurrent wheezing that is poorly responsive to aggressive therapy including oral corticosteroids.

The syndrome of autoimmune interstitial nephritis and membranous nephropathy.

A 2-year-old male patient was evaluated for Fanconi syndrome with hypertension and failure to thrive. Renal biopsy revealed autoimmune interstitial nephritis with membranous nephropathy. The patient developed autoimmune hemolytic anemia and intractable diarrhea with villous atrophy of the jejunum. He progressed to end-stage renal disease and was transplanted without recurrent disease. Immune work-up done prior to immunosuppressive therapy showed marked elevation of IgE. Studies of T lymphocyte cytokine production showed normal production of interleukin-4 but depressed levels of interferon-gamma. The simultaneous occurrence of autoimmune interstitial nephritis and membranous nephropathy in a young male represents a unique syndrome. Abnormalities of T lymphocyte subpopulations and their cytokines may be involved in the pathogenesis of this disorder.

Comparison of two disposable plastic skin test devices with the bifurcated needle for epicutaneous allergy testing.

BACKGROUND: The Greer DermaPIK and the Lincoln Diagnostics Duotip-Test are frequently used plastic, disposable, allergy skin testing devices. OBJECTIVES: To compare the prick method of using the bifurcated needle and DermaPIK with the Duotip-Test using both the scratch (rotation) and prick methods for sensitivity, precision, and level of discomfort. METHODS: Skin-testing was done with histamine and saline on the back in triplicate on 24 volunteers (mean age 32.8, seven males). Wheal and erythema were measured and a photograph was taken. Discomfort was rated on an analog scale. RESULTS: The bifurcated needle and the Duotip-Test prick technique had significantly smaller histamine wheal and erythema responses than either the DermaPIK prick or Duotip-Test scratch techniques (P < .05). The Duotip-Test scratch produced significantly larger wheals (mean 1.1 mm, P < .001) to saline than the other three methods. Erythema to saline by Duotip-Test scratch (mean 3.16 mm) was significantly larger than the bifurcated needle (mean 1.2 mm, P < .001) and Duotip-Test prick method (mean 1.6 mm, P < .01). There was no statistical difference in the histamine coefficient of variation among the four methods. The Duotip-Test scratch method was rated significantly higher in patient discomfort (mean 21.6, P < .05) than the bifurcated needle (mean 7.8). No differences in discomfort were noted between the other methods. CONCLUSIONS: The Duotip-Test scratch method had the largest mean wheal/erythema to histamine and the lowest CV. It had the most dermatographism and was more uncomfortable than the other methods. The other devices and methods were very similar in response to histamine and saline, and to precision and discomfort.

Basement shower hypersensitivity pneumonitis secondary to Epicoccum nigrum.

Two children developed hypersensitivity pneumonitis after extensive exposure to an unventilated basement shower. Commercial precipitin panels were negative. After home inspection, individual mold species were isolated from the household and extracted. Precipitating antibodies to Epicoccum nigrum were found in both children. Resolution of the hypersensitivity pneumonitis occurred with avoidance and glucocorticosteroid therapy. E nigrum is a newly identified etiologic agent for hypersensitivity pneumonitis found in a mold-contaminated home.

Comparison of three methods of using the DermaPIK with the standard prick method for epicutaneous skin testing.

BACKGROUND: The Greer DermaPIK is a plastic disposable device used for epicutaneous allergy skin testing. Various methods have been proposed for applying this device. The recommended methods are to use it as either a punch or scratch device. A third method- the prick, uses the device similarly to standard prick testing with the bifurcated needle. OBJECTIVE: To compare three methods of using the DermaPIK for epicutaneous skin testing with the bifurcated needle. METHODS: Twenty volunteers with a mean age of 30 years (range 6 to 45) were skin tested using saline and histamine. Each test was done in triplicate on the back. Discomfort for each technique was rated on a scale from 0 to 100. Wheal and erythema were measured at 15 minutes and a photograph was taken. RESULTS: The scratch method was rated highest in discomfort. The mean coefficient of variation for the punch method was 39.2% for erythema which was significantly higher than for the other methods (P < .0001). The scratch method had a mean wheal and erythema to saline of 3.85 +/- 1.3 and 6.23 +/- 2.2 that was significantly larger than the other methods (P < .001). There was no difference between the prick method and the bifurcated needle for discomfort or size of wheal/erythema to saline or histamine. CONCLUSIONS: The punch method is too imprecise and the scratch method produces considerable dermatographism. The prick method was comparable to the bifurcated needle in discomfort, sensitivity and precision.

Association of kyphomelic dysplasia with severe combined immunodeficiency.

Kyphomelic dysplasia is a distinct, rare, skeletal dysplasia with short angulated femora, bowing of long bones, short ribs, narrow thorax, and metaphyseal abnormalities. While immune deficiency occurs in other short stature/short-limb skeletal dysplasias and cartilage-hair hypoplasia, it has not been described with kyphomelic dysplasia. We report on an infant with this disorder who had profound humoral and cellular immunologic abnormalities consistent with severe combined immune deficiency (SCID). The infant died at age 2 months of overwhelming cytomegalovirus pneumonia. Kyphomelic dysplasia, as with other short stature/short-limb skeletal dysplasias, can be associated with immune deficiency and immune function should be investigated when this disorder is identified.

Immunoglobulins and IgG subclasses in children following severe head injury.

OBJECTIVE: To study immunoglobulin production after severe blunt head trauma in children. DESIGN: Serum for IgG, IgM, IgA, IgE, and IgG subclasses were drawn from 10 children admitted with severe head injury (ISS 31.2, GCS 5.4) on day 1, 7, 14 and 21 after injury. RESULTS: 5 of the 10 patients developed infection between 7 and 14 days and 2 died of complications of pneumonia. On day 1, IgM levels averaged 95.6% of the mean of the age-specific normal controls. By day 7, IgM levels averaged 383% (p < 0.01). While all patients were within the age-specific normal range (+/- 2 SD) on day 1, 7 of 10 patients were above the normal range by day 7. There was no difference in IgM levels between infected and non-infected patients. Five patients were below the age-specific normal range for IgG on day 1, with 3 still low on day 7. By day 21, IgG levels averaged 141% of the mean of the age-specific normal controls. IgG subclasses followed a pattern similar to total IgG levels. Marked increases in IgE were seen in 3 patients. CONCLUSIONS: IgM levels increased dramatically in all patients within seven days of the injury. While 50% of these children had a deficit of IgG in the first week, total IgG and IgA levels increased after injury, but not as rapidly as IgM levels. Unlike pediatric burn patients, there is no persistent hypogammaglobulinemia following severe blunt trauma in children.

Safety and efficacy of intravenous immunoglobulin prophylaxis in pediatric head trauma patients: a double-blind controlled trial.

Infection is one of the major complications of severe head trauma in children. To assess whether intravenous immunoglobulin (IVIg) decreases the incidence of secondary infection after head injury in children, a randomized, double-blind trial was performed. Thirty-three children (mean age, 6.67 years; mean injury severity score, 32.8; mean Glasgow coma score, 6.1) with severe head injuries were enrolled; 1 child was excluded, 18 received IVIg, and 14 received the placebo preparation. Four hundred milligrams per kilogram of IVIg or albumin placebo was administered within 48 hours of admission. IgG levels were obtained before the infusion and then 1 week later. Patients were monitored for evidence of infection for the next 21 days. There was a 66% increase in mean IgG levels in the treatment group compared with 45% in the control group (P = .057). One death occurred in the IVIg group and two in the placebo group. No significant differences in the incidence of pneumonia, sepsis, presumed sepsis, or any other type of infection was noted. There was no difference in the number of days on mechanical ventilation or in number of hospital days. There were no side effects. It is concluded that prophylactic administration of commercial IVIg at a dose of 400 mg/kg, although safe, had no effect on the incidence of secondary infections in children with severe head injuries.