Common Variable Immunodeficiency: A Standardized Patient Case for Second-Year Medical Students

INTRODUCTION

Common variable immunodeficiency (CVID) is the most common symptomatic antibody deficiency, with a prevalence of 0.6-6.9 depending on the population studied. In contrast to other primary immunodeficiency diseases (PIDDs), symptoms may not appear until the third decade of life. Lack of recognition of CVID is a persistent problem. Myriad confounding clinical phenotypes and frequent infections, including autoimmunity, malignancy, chronic lung disease, granulomatous disease, and gastrointestinal disease, complicate the diagnosis. Often it is years before a diagnosis is made, leading to irreversible morbidities and mortality.

METHODS

Second-year medical students are introduced to CVID during their session on PIDDs that occurs during the immunology/rheumatology course. To assess students' recognition of CVID, a 15-minute OSCE encounter was created that included a simulation of lung sounds (rhonchi), physical exam cards (clubbing, otitis media with effusion), and moulage of skin (petechiae). A standardized patient (SP) portrayed a patient requesting antibiotics for a sinus infection. Students were tasked to both interview the patient and perform a hypothesis-driven physical exam. A postencounter exercise queried the students on their differential diagnosis and their rationale.

RESULTS

Item analysis of the case showed high levels of difficulty and strong discrimination between high- and low-performing students in both communication skills and clinical reasoning in CVID.

DISCUSSION

This SP encounter can be used in both formative and summative assessments to measure the recognition of CVID.

Catholic Identity in New Sponsorship Models

Life in the church changes and evolves. So do the ministries of the church, for the church’s works must remain relevant as the times change and evolve. Thus the relationship between the church and the Catholic health care ministry has been adapting to a modern era in which founding congregations gradually relinquish control of the entities they created.

Meat lipid profiles: a comparison of meat from domesticated and wild Southern African animals

BACKGROUND

The link between meat and various chronic diseases has been qualified recently, and is now accepted as being related to the amount of saturated fat present. Other work has shown differences in total lipid profiles between meat from 'wild' and 'domesticated' animals, with the 'wild' reflecting higher levels of polyunsaturated and lower saturated fat. This study assessed both meat types from South African sources.

MATERIALS AND METHODS

All 'wild' meat samples were obtained fresh from a specialist restaurant. All 'domestic' samples were purchased from commercial outlets. Lipids were quantified using thin layer and gas chromatography.

RESULTS

All of the domestic meats had higher saturated and lower polyunsaturated lipid levels than the wild meats. There was little difference between the phosphoglyceride, but large differences between the triacylglycerol, fractions.

CONCLUSION

Meat from animals raised under intensive agricultural methods in Africa is similar to those from the rest of the world, while wild meats are markedly different.

Memory, language, and praxis in Alzheimer's disease: norms for outpatient clinical trial populations

The cognitive subscale of the Alzheimer's Disease Assessment Scale (ADAS-Cog) is designed specifically to assess memory, language, and praxis dysfunctions characteristic of Alzheimer's disease (AD). In this report, we use data from 1,648 AD participants in two identical 26-week multicenter drug trials to derive clinical trial population-based norms for ADAS-Cog subtest scores. All 11 ADAS-Cog item scores were sensitive to differences in dementia severity judged either by baseline Mini-Mental State Exam (MMSE) scores or by Global Deterioration Scale (GDS) stage of dementia. Using ADAS-Cog subtest scores alone, 85 percent of GDS 4 subjects and 69 percent of GDS 5 subjects could be classified correctly. In a stepwise discriminant analysis, orientation was the item with the greatest discriminatory power between subjects with GDS 4 and GDS 5 stages of dementia. ADAS-Cog subtest scores also varied by age, gender, educational level, and concurrent use of anti-inflammatory drugs or estrogen (in women). Such normative data may facilitate the selection of appropriate outcome measures to investigate differential treatment effects on specific cognitive domains or in specific AD subpopulations.

Nasal versus oral midazolam for sedation of anxious children undergoing laceration repair

STUDY OBJECTIVE

To compare the efficacy and safety of a single dose of midazolam, as an oral solution of 0.5 mg/kg, or nasal drops of 0.25 mg/kg, in children undergoing emergency department laceration repair.

DESIGN

Double-blind, double-placebo, randomized trial. Children underwent standard wound care when judged to demonstrate a reduction in anxiety following study medication.

PARTICIPANTS

Fifty-eight patients between 1 and 10 years of age with uncomplicated lacerations judged to be anxious by emergency physicians.

RESULTS

An anxiety score and vital signs were recorded at routine intervals. Groups were comparable with respect to age, laceration characteristics, initial vital signs, and anxiety scores. Both groups demonstrated reductions (mean +/- SD) in anxiety scores over time (P < .05; maximum at 10 minutes; 1.2 +/- 0.9 mm for nasal and 0.8 +/- 1.3 for oral), with no significant differences between groups (repeat-measures ANOVA). Median observer-rated effectiveness using a visual analog scale (maximum effectiveness, 10 mm) was not significantly different between groups: nasal, 7.6 mm and oral, 6.9 (Mann-Whitney U test: minimum detectable difference, 0.7, with alpha = 0.05 and beta = 0.2). Complications were judged to be minor only, and were more frequent in the nasal group (5 of 28, 4 with nasal burning) versus 1 of 26 in the oral group. Time from midazolam to ED discharge was not significantly different between groups: nasal, 54 +/- 15 minutes and oral, 57 +/- 16 minutes.

CONCLUSION

A single dose of oral or nasal midazolam results in reduced anxiety and few complications in selected children undergoing laceration repair in the ED. The oral route was associated with fewer administration problems.

The use of corticosteroids in croup: a survey

The use of corticosteroids to treat laryngotracheobronchitis (croup) is controversial. Although some evidence supports the efficacy of treating hospitalized patients with croup, there is no published information on the use of corticosteroids in the outpatient population. We sought to determine what the current practice in the use of corticosteroids to treat croup was in our community. One hundred thirty-eight questionnaires were mailed to pediatricians and family practitioners in our geographic region. One hundred twelve surveys were completed and returned. The majority of responding physicians used corticosteroids to treat both inpatients and outpatients with croup at least some of the time. A significantly greater percentage used them to treat hospitalized patients (93%) compared with nonhospitalized patients (68%). The drug used by the majority of respondents was dexamethasone (87% in treating inpatients, 56% in treating outpatients). The initial dosage, cumulative dosage, number of doses, and route of administration varied greatly among the respondents. This survey demonstrates that most physicians in our area are using corticosteroids to treat both hospitalized and non-hospitalized patients with croup. However, the form of drug used, dosing regimen, and route of administration are highly variable. This survey highlights the need for clinical studies to assess the efficacy of using corticosteroids to treat outpatients with croup and to determine how best to use them.

Measurement of androgen sensitivity in the human prostate in in vitro three-dimensional histoculture

We have adopted an in vitro three-dimensional histoculture technique for assay of androgen sensitivity in explants of human benign prostatic tissue. The assay is based on the uptake of 3H-thymidine/micrograms protein in explants of prostate incubated in parallel with dihydrotestosterone (DHT) and hydroxyflutamide (HF) controls. The ratio of 3H-thymidine/micrograms protein in DHT treated samples per 3H-thymidine/micrograms protein in HF treated samples provides an index of androgen sensitivity. The DHT/HF index measured in 24 BPH specimens averaged 3.6. To determine the specificity of the HF effect, we measured the DHT/HF index in a single prostate at different concentrations of HF in the presence of fixed concentrations of DHT (2 x 10(-8) M) and noted a dose-response relationship. In addition we noted no effects of HF on 3H-thymidine incorporation over a range of 2 x 10(-4)M compared to 2 x 10(-7)M, except at the highest concentration. Of surprise was the finding of an average DHT/HF index in 5 different nonprostate tissues, including breast, uterus, colon, kidney, and thyroid, that was similar to the index found in prostates. We plan to adapt this androgen sensitivity assay to measure the DHT/HF index in biopsy-size samples of prostate, since such an assay could then be utilized to determine androgen sensitivity in individual patients with prostate cancer.

Human cortical neuronal cell line: establishment from a patient with unilateral megalencephaly

A cell line has been established in continuous culture of human cerebral cortical neurons obtained from a patient with unilateral megalencephaly, a disorder associated with continued proliferation of immature neuronal cells. When differentiated in the presence of nerve growth factor, 1-isobutyl-3-methylxanthine, and dibutyryl adenosine 3',5'-monophosphate (cAMP), the cells display mature neuronal morphology with numerous long, extensively branched processes with spines and varicosities. The cells stain positively for neurofilament protein and neuron-specific enolase (selective neuronal markers) but are negative for glial markers, such as glial fibrillary acidic protein, S-100, and myelin basic protein. The cells also stain positively for the neurotransmitters gamma-aminobutyric acid (GABA), glutamate, somatostatin, cholecystokinin-8, and vasoactive intestinal polypeptide. These cells may facilitate characterization of neurons in the human central nervous system.