Multifocal bone marrow involvement in cat-scratch disease

We describe 2 children with prolonged fever of unknown origin and prominent skeletal pain who had multifocal bone disease caused by Bartonella infection. Initial radiologic studies, including plain films, radionuclide scintigraphy and computed tomography, yielded negative results. In both cases, magnetic resonance imaging revealed multiple enhancing bone marrow lesions consistent with clinical symptoms. Microbiologic diagnoses were established serologically.

Ticks and tick paralysis: imaging findings on cranial MR

Tick paralysis is an acute, progressive, and potentially fatal muscle paralysis secondary to a toxin secreted by a pregnant tick during a bite. Although tick bites can occur anywhere on the body, ticks are frequently overlooked on the scalp because of overlying hair. Children with acute neurologic symptoms frequently undergo MR scanning that may incidentally reveal the offending tick. Timely identification and removal of the tick leads to rapid recovery from tick paralysis. We report the MRI findings at 1.5 T of tick paralysis with an attached tick.

Sex differences in nevirapine rash

Nevirapine is a nonnucleoside reverse transcriptase inhibitor (NNRTI) that has the most common treatment limiting side effect of rash. Severe rash has been observed in 3% of patients taking nevirapine in clinical trials, 85% of whom were men. In a multicenter, retrospective cohort study of all patients who received nevirapine over a 5-year period, severe rash was noted in 9 of 95 women and 3 of 263 men (risk ratio [RR], 8.31; 95% confidence interval [CI], 2.3-30.0; P=.005). Women were more likely to discontinue nevirapine therapy because of rash (RR, 4.5; 95% CI, 1. 9-10.5; P=.0005). After adjusting for age and baseline CD4 cell count in multivariate analysis, women had a 7-fold increase in risk for severe rash and were 3.5 times more likely to discontinue nevirapine therapy. In women of reproductive age for whom contraception may occur, nevirapine remains the NNRTI of choice. Recognition of sex differences in this severe adverse event will be important in prescribing nevirapine.

Neonatal bilirubin testing practices: reports from 312 laboratories enrolled in the Colege of American Pathologists Excel Proficiency Testing Program

OBJECTIVE

To characterize laboratory practices for neonatal bilirubin testing and to identify opportunities for improvement.

DESIGN

A voluntary self-assessment questionnaire was used to assess the laboratory practices of 312 laboratories subscribing to the College of American Pathologists (CAP) Excel Chemistry Proficiency Testing Program.

RESULTS

A range of preanalytic and analytic practices were reported. The most notable problems identified were the use of overly long capillary puncture devices (17.8%), failure to protect the specimen from light prior to analysis (3.4%), failure to use a control containing >171 micromol/L bilirubin (26.1%), use of single-level control (4.2%), and lack of established linearity limits (7.0%).

CONCLUSION

Opportunities exist to improve specimen collection, processing, and analysis for some physician-office and small-hospital laboratories.

Computer instruction in learning concepts of streptococcal pharyngitis

OBJECTIVE

To evaluate a computer-assisted instruction unit covering the basic concepts of streptococcal pharyngitis for effectiveness as a learning tool.

DESIGN

Randomized control trial.

SETTING

A medical school associated with a tertiary care hospital.

PARTICIPANTS

Third-year medical students on a pediatric clerkship from December 1, 1992, to October 31, 1993.

INTERVENTION

Students were randomized into a study or a control group and given a pretest on streptococcal pharyngitis. The study group then completed the computer-assisted instruction unit. No attempt was made to distinguish among the clinical experiences of the two groups during the next 4 weeks, after which a second test on streptococcal pharyngitis was given to both groups.

MAIN OUTCOME MEASURES

Outcome was measured by scores (percentage correct) from tests given at day 1 and week 4 of the clerkship.

RESULTS

The posttest scores of the study group increased by an average of 12.1 above the pretest scores, but the scores of the control group were only 3.4 points higher. The difference between these increases is statistically significant (P < .01, Student's t test).

CONCLUSION

Short, well-designed computer-assisted instruction units can be effective tools in medical education.

Physician office laboratory education and training in primary care residency programs

OBJECTIVE

To assess the status of office laboratory residency education and training in family practice, internal medicine, obstetrics and gynecology, and pediatric residency programs.

DESIGN

A single mailed survey to 1299 residency programs from December 1992 to February 1993.

PARTICIPANTS

Primary care residency directors from 507 (39%) of 1299 programs.

INTERVENTIONS

A 27-item survey of residency-based office laboratory practices, education, training, and resources.

MAIN OUTCOME MEASURES

Differences between specialties in provision and quantity of office laboratory education and training, presence of a residency-based office laboratory, laboratory classification under the Clinical Laboratory Improvement Amendments, and available laboratory tests.

RESULTS

Of those responding, office laboratories were present in 89% of family practice, 19% of internal medicine, 29% of obstetrics and gynecology, and 24% of pediatrics residency programs. Laboratory training was available at 60% of family practice, 16% of internal medicine, 15% of obstetrics and gynecology, and 30% of pediatrics programs. The median number of hours of formal skills training was 10 hours for family practice residency programs but less than 2 hours for the other specialties. Only 25% of the programs reported educational assistance from pathologists. Merely 4% of the programs had postassessment examinations and 2% awarded certificates of achievement. A majority of family practice programs performed waivered tests and physician-performed microscopy tests, but moderately complex tests were performed in less than 50% of family practice programs.

CONCLUSIONS

Family practice residency programs provide more office laboratory training for residents than other specialties. There is a need for improved residency training in the basics of office laboratory practice.

Effect of institutional prestige on reviewers' recommendations and editorial decisions

OBJECTIVE

To determine whether manuscripts from institutions with greater prestige are more likely to be recommended for publication by reviewers and to be accepted for publication.

DESIGN

Retrospective study of reviewers' recommendations and editorial decisions for manuscripts from the United States received at the Journal of Pediatrics between January 1 and July 31, 1992. Manuscripts were classified as major papers or as brief reports. Institutions were ranked in quintiles according to the monetary value of grants funded by the National Institutes of Health. Reviewers' recommendations were classified as reject, reconsider, or accept, and editorial decisions as accept or reject, without regard to qualifying recommendations.

RESULTS

For the 147 brief reports, lower institutional rank was associated with lower rates of recommendation for acceptance and of selection for publication. For the 258 major papers, however, there was no significant relationship between institutional rank and either the reviewers' recommendations or the acceptance rate. Similar results were found when the manuscripts were divided into five numerically equal groups according to institutional rank.

CONCLUSIONS

Major manuscripts from institutions with greater prestige were no more likely to be recommended or accepted for publication than those from institutions with lesser prestige. In contrast, the likelihood of recommendation for acceptance and of selection for publication of brief reports appeared to correlate with the prestige of the institution.

Effect of acceptance or rejection on the author's evaluation of peer review of medical manuscripts

To determine whether authors of rejected manuscripts would evaluate the editorial review process less favorably than would authors of manuscripts accepted for publication, a questionnaire was sent to solicit evaluations of the quality of the reviews that had led to the rejection or acceptance of manuscripts submitted to the Journal of Pediatrics. Similar evaluations of the editor's letter were also sought. Authors were more likely to respond to the questionnaire if their manuscripts had been accepted and were more likely to complete the questionnaire thoroughly. Authors of accepted manuscripts evaluated the editor's communication more favorably than did the authors of manuscripts not accepted for publication, but the evaluations of the reviews were not significantly different. Most authors utilized the reviews to modify their manuscripts before submitting them to another journal.

Problems identified by secondary review of accepted manuscripts

To test the hypothesis that no important deficits would be identified on further review of accepted manuscripts, and that such manuscripts would be recommended for publication on rereview, we sent manuscripts that had been accepted for publication, after review and revision, for rereview by new referees who were unaware of the status of the manuscripts. Each review was evaluated independently by two assistant editors to determine whether substantive criticisms were identified by the new reviewers. The majority of manuscripts were thought by the new reviewers to have defects that warranted further revision, but the problems noted were often dissimilar. However, 80% of the manuscripts were recommended for publication and others were judged suitable for publication, although not at a high priority. The assistant editors frequently differed in their judgments whether a given criticism of a reviewer warranted further revision; nevertheless, there was infrequent disagreement regarding the basic decision for acceptance or rejection.

Kimura's disease: report of a pediatric case in the United States

A 14-year-old male adolescent is described with a 6-year history of active lymphadenopathy, skin rash, peripheral blood eosinophilia, and markedly elevated serum-IgE level. Complete histopathologic and immunologic evaluations established the diagnosis of Kimura's disease as first described in Japan. Because of its relative infrequency and varied features, this disorder can be difficult to diagnose when it is encountered in the United States.

Giardiasis causing urticaria in a child

We report an association between giardiasis and chronic urticaria and review the few previous cases in the literature. An unusual aspect of our case was the intensification of the urticarial response with antiprotozoal chemotherapy. We discuss the clinical features in terms of the limited current knowledge concerning immunologic mechanisms in giardiasis and the antigenic structure of Giardia lamblia.

Two cases of dipylidiasis (dog tapeworm infection) in children: update on an old problem

Children in households with dogs and cats may become infected with the dog tapeworm more frequently than suspected. Because of age-appropriate hand-to-mouth exploration, young infants and toddlers, through contact with fleas on pets, floors, and furnishings, are particularly susceptible. Knowledge of the life cycle of this animal parasite and the manner in which children acquire and demonstrate infection can lead to early diagnosis and effective treatment.

Bacteremia in 28 ambulatory children: relationship to pneumonitis and meningitis

Bacteremia with known pathogens was documented in 28 acutely ill, febrile outpatients during a 29-month period. All of the children were previously healthy and were initially managed as outpatients. Eight patients presented with no identifiable focus of infection. Twenty patients had either otitis media or pneumonitis. An association between otitis media and bacteremia with H. influenzae type b was noted in 5 patients. Bacterial meningitis occurred subsequently in 7 patients (25%); 1 death occurred in this group. The blood culture, as an outpatient procedure, was helpful in establishing a bacterial etiology in selected children with either high fever (with or without otitis media), febrile seizures, or pneumonia. In addition, the positive blood culture was a vital aid in identifying the young child at risk for meningitis.