Assessing clinical reasoning skills following a virtual patient dizziness curriculum

OBJECTIVES

Dizziness is a common medical symptom that is frequently misdiagnosed. While virtual patient (VP) education has been shown to improve diagnostic accuracy for dizziness as assessed by VPs, trainee performance has not been assessed on human subjects. The study aimed to assess whether internal medicine (IM) interns after training on a VP-based dizziness curriculum using a deliberate practice framework would demonstrate improved clinical reasoning when assessed in an objective structured clinical examination (OSCE).

METHODS

All available interns volunteered and were randomized 2:1 to intervention (VP education) vs. control (standard clinical teaching) groups. This quasi-experimental study was conducted at one academic medical center from January to May 2021. Both groups completed pre-posttest VP case assessments (scored as correct diagnosis across six VP cases) and participated in an OSCE done 6 weeks later. The OSCEs were recorded and assessed using a rubric that was systematically developed and validated.

RESULTS

Out of 21 available interns, 20 participated. Between intervention (n=13) and control (n=7), mean pretest VP diagnostic accuracy scores did not differ; the posttest VP scores improved for the intervention group (3.5 [SD 1.3] vs. 1.6 [SD 0.8], p=0.007). On the OSCE, the means scores were higher in the intervention (n=11) compared to control group (n=4) for physical exam (8.4 [SD 4.6] vs. 3.9 [SD 4.0], p=0.003) and total rubric score (43.4 [SD 12.2] vs. 32.6 [SD 11.3], p=0.04).

CONCLUSIONS

The VP-based dizziness curriculum resulted in improved diagnostic accuracy among IM interns with enhanced physical exam skills retained at 6 weeks post-intervention.

Exploring Clinical Lessons Learned by Experienced Hospitalists from Diagnostic Errors and Successes

BACKGROUND

Diagnostic errors cause significant patient harm. The clinician's ultimate goal is to achieve diagnostic excellence in order to serve patients safely. This can be accomplished by learning from both errors and successes in patient care. However, the extent to which clinicians grow and navigate diagnostic errors and successes in patient care is poorly understood. Clinically experienced hospitalists, who have cared for numerous acutely ill patients, should have great insights from their successes and mistakes to inform others striving for excellence in patient care.

OBJECTIVE

To identify and characterize clinical lessons learned by experienced hospitalists from diagnostic errors and successes.

DESIGN

A semi-structured interview guide was used to collect qualitative data from hospitalists at five independently administered hospitals in the Mid-Atlantic area from February to June 2022.

PARTICIPANTS

12 academic and 12 community-based hospitalists with ≥ 5 years of clinical experience.

APPROACH

A constructivist qualitative approach was used and "reflexive thematic analysis" of interview transcripts was conducted to identify themes and patterns of meaning across the dataset.

RESULTS

Five themes were generated from the data based on clinical lessons learned by hospitalists from diagnostic errors and successes. The ideas included appreciating excellence in clinical reasoning as a core skill, connecting with patients and other members of the health care team to be able to tap into their insights, reflecting on the diagnostic process, committing to growth, and prioritizing self-care.

CONCLUSIONS

The study identifies key lessons learned from the errors and successes encountered in patient care by clinically experienced hospitalists. These findings may prove helpful for individuals and groups that are authentically committed to moving along the continuum from diagnostic competence towards excellence.

Osmotic Demyelination After Rapid Correction of Hyperosmolar Hyperglycemia

Osmotic demyelination syndrome (ODS) is seen due to an overt rise in serum osmolality, most often during rapid correction of chronic hyponatremia. We present the case of a 52-year-old patient who presented with polydipsia, polyuria, and elevated blood glucose with rapid correction of glucose levels under five hours and developed dysarthria, left-sided neglect, and unresponsiveness to light touch and pain in the left extremities on the second day of hospitalization. MRI revealed restricted diffusion in the central pons, extending into extrapontine areas suggestive of ODS. Our case highlights the importance of cautious correction of serum hyperglycemia and monitoring serum sodium levels in patients with a hyperosmolar hyperglycemic state (HHS).

“Learning from the experts” – a novel advanced cadaveric course for Gynaecological Oncology (GO) Cytoreductive Surgery

Background: Ovarian cancer cytoreductive surgery necessitates the use of advanced Simulation-Based Learning (SBL) to optimise skill-based teaching and achieve technical proficiency. Objective: We describe and appraise the role of a novel postgraduate cadaveric course for cytoreductive surgery for advanced ovarian/fallopian tube or primary peritoneal cancer. Materials and Methods: Several consultant-level surgeons with expertise in upper gastrointestinal, colorectal, hepatobiliary and urological surgery, were invited to teach their counterpart GO surgeons. The 2-day course curriculum involved advanced dissections on thiel-embalmed cadavers. All dissections included applicable steps required during GO cytoreductive surgeries. Outcome measures: We used a feedback questionnaire and structured interviews to capture trainers and delegates views respectively. Results: All delegates reported a positive educational experience and improvement of knowledge in all course components. There was no difference in the perception of feedback across junior versus senior consultants. Trainers perceived this opportunity as a “2-way learning” whether they got to explore in depth the GO perspective in how and which of their skills are applicable during cytoreductive surgery. Conclusions: Collaborating with other surgical specialities promotes a “learning from the experts” concept and has potential to meet the rapidly increased demand for multi-viscera surgical excellence in GO surgery. What’s new? The concept of involving experts from other surgical disciplines in advanced cadaveric courses for cytoreductive surgery in ovarian cancer, will solidify the effort to achieve excellence in the GO training. Such courses can be essential educational adjunct for most GO fellowships.

Controlled evaLuation of Angiotensin Receptor Blockers for COVID-19 respIraTorY disease (CLARITY): statistical analysis plan for a randomised controlled Bayesian adaptive sample size trial

The CLARITY trial (Controlled evaLuation of Angiotensin Receptor Blockers for COVID-19 respIraTorY disease) is a two-arm, multi-centre, randomised controlled trial being run in India and Australia that investigates the effectiveness of angiotensin receptor blockers in addition to standard care compared to placebo (in Indian sites) with standard care in reducing the duration and severity of lung failure in patients with COVID-19. The trial was designed as a Bayesian adaptive sample size trial with regular planned analyses where pre-specified decision rules will be assessed to determine whether the trial should be stopped due to sufficient evidence of treatment effectiveness or futility. Here, we describe the statistical analysis plan for the trial and define the pre-specified decision rules, including those that could lead to the trial being halted. The primary outcome is clinical status on a 7-point ordinal scale adapted from the WHO Clinical Progression scale assessed at day 14. The primary analysis will follow the intention-to-treat principle. A Bayesian adaptive trial design was selected because there is considerable uncertainty about the extent of potential benefit of this treatment.

Trial registration

ClinicalTrials.gov NCT04394117. Registered on 19 May 2020Clinical Trial Registry of India CTRI/2020/07/026831

Version and revisions

Version 1.0. No revisions.

A Nationwide Study Examining Deafness Among Hospitalized Adults

Background It is unknown whether hospital outcomes differ among nonspeaking deaf patients compared to those without this disability. Objective This article aims to compare clinical outcomes and utilization data among patients with and without deafness. Design This study used a retrospective cohort study. Setting and Participants The participants included Nationwide Inpatient Sample, year 2017, hospitalized adults with and without diagnostic codes related to deafness and inability to speak. Method Multiple logistic and linear regression were used to compare in-hospital outcomes. Results Thirty million four hundred one thousand one hundred seventeen adults were hospitalized, and 7,180 had deafness and inability to speak related coding. Patients with deafness were older (mean age ± SEM: 59.2 ± 0.51 vs. 57.9 ± 0.09 years, p = .01), and less likely female (47.0% vs. 57.7%, p < .01) compared to controls. Those with deafness had more comorbidities compared to the controls (Charlson comorbidity score ≥ 3: 31.2% vs. 27.8%, p < .01). Mortality was higher among deaf versus controls (3.6% vs. 2.2%; p < .01); this translated into higher adjusted odds of mortality (adjusted odds ratio = 1.7. [confidence interval (CI) 1.3-2.4]; p = .01). Deaf patients had lower odds of being discharged home compared to controls {aOR} = 0.6, (CI) 0.55-0.73]; p < .01. Length of stay was longer (adjusted mean difference = 1.5 days CI [0.7-2.3]; p < .01) and hospital charges were higher, but not significantly so (adjusted mean difference = $4,193 CI [-$1,935-$10,322]; p = .18) in patients with deafness. Conclusions Hospitalized nonspeaking deaf patients had higher mortality and longer hospital stays compared to those without this condition. These results suggest that specialized attention may be warranted when deaf patients are admitted to our hospitals in hopes of reducing disparities in outcomes. Supplemental Material https://doi.org/10.23641/asha.14336663.

Real-world virtual patient simulation to improve diagnostic performance through deliberate practice: a prospective quasi-experimental study

OBJECTIVES

Diagnostic errors are pervasive in medicine and most often caused by clinical reasoning failures. Clinical presentations characterized by nonspecific symptoms with broad differential diagnoses (e.g., dizziness) are especially prone to such errors.

METHODS

We hypothesized that novice clinicians could achieve proficiency diagnosing dizziness by training with virtual patients (VPs). This was a prospective, quasi-experimental, pretest-posttest study (2019) at a single academic medical center. Internal medicine interns (intervention group) were compared to second/third year residents (control group). A case library of VPs with dizziness was developed from a clinical trial (AVERT-NCT02483429). The approach (VIPER - Virtual Interactive Practice to build Expertise using Real cases) consisted of brief lectures combined with 9 h of supervised deliberate practice. Residents were provided dizziness-related reading and teaching modules. Both groups completed pretests and posttests.

RESULTS

For interns (n=22) vs. residents (n=18), pretest median diagnostic accuracy did not differ (33% [IQR 18-46] vs. 31% [IQR 13-50], p=0.61) between groups, while posttest accuracy did (50% [IQR 42-67] vs. 20% [IQR 17-33], p=0.001). Pretest median appropriate imaging did not differ (33% [IQR 17-38] vs. 31% [IQR 13-38], p=0.89) between groups, while posttest appropriateness did (65% [IQR 52-74] vs. 25% [IQR 17-36], p<0.001).

CONCLUSIONS

Just 9 h of deliberate practice increased diagnostic skills (both accuracy and testing appropriateness) of medicine interns evaluating real-world dizziness 'in silico' more than ∼1.7 years of residency training. Applying condensed educational experiences such as VIPER across a broad range of common presentations could significantly enhance diagnostic education and translate to improved patient care.

Documentation of Clinical Reasoning in Admission Notes of Hospitalists: Validation of the CRANAPL Assessment Rubric

BACKGROUND

High-quality documentation of clinical reasoning is a professional responsibility and is essential for patient safety. Accepted standards for assessing the documentation of clinical reasoning do not exist.

OBJECTIVE

To establish a metric for evaluating hospitalists' documentation of clinical reasoning in admission notes.

STUDY DESIGN

Retrospective study.

SETTING

Admissions from 2014 to 2017 at three hospitals in Maryland.

PARTICIPANTS

Hospitalist physicians.

MEASUREMENTS

A subset of patients admitted with fever, syncope/dizziness, or abdominal pain were randomly selected. The nine-item Clinical Reasoning in Admission Note Assessment & Plan (CRANAPL) tool was developed to assess the comprehensiveness of clinical reasoning documented in the assessment and plans (A&Ps) of admission notes. Two authors scored all A&Ps by using this tool. A&Ps with global clinical reasoning and global readability/clarity measures were also scored. All data were deidentified prior to scoring.

RESULTS

The 285 admission notes that were evaluated were authored by 120 hospitalists. The mean total CRANAPL score given by both raters was 6.4 (SD 2.2). The intraclass correlation measuring interrater reliability for the total CRANAPL score was 0.83 (95% CI, 0.76-0.87). Associations between the CRANAPL total score and global clinical reasoning score and global readability/clarity measures were statistically significant (P < .001). Notes from academic hospitals had higher CRANAPL scores (7.4 [SD 2.0] and 6.6 [SD 2.1]) than those from the community hospital (5.2 [SD 1.9]), P < .001.

CONCLUSIONS

This study represents the first step to characterizing clinical reasoning documentation in hospital medicine. With some validity evidence established for the CRANAPL tool, it may be possible to assess the documentation of clinical reasoning by hospitalists.

Differences in healthcare outcomes between teaching and non teaching hospitals for patients with delirium: a retrospective cohort study

BACKGROUND

The physician workforce at teaching hospitals differs compared to non-teaching hospitals, and data suggest that patient outcomes may also be dissimilar. Delirium is a common, costly disorder among hospitalized patients and approaches to care are not standardized.

OBJECTIVE

This study set out to explore differences in healthcare outcomes between teaching and non-teaching hospitals for patients admitted with delirium.

DESIGN

Retrospective cohort analysis.

SETTING AND PARTICIPANTS

We used the 2014 Nationwide Inpatient Sample database. Adult patients (≥18 years of age) hospitalized in acute-care hospitals in the USA with delirium (defined with ICD-9 code) were studied.

MAIN OUTCOME MEASURES

The primary outcome was in-hospital all-cause mortality. Secondary outcomes were discharge status and several measures of healthcare resource utilization: length of stay, total hospitalization costs and multiple procedures performed.

RESULTS

In 2014, out of 57 460 adult patients admitted to hospitals with delirium, 58.4% were hospitalized at teaching hospitals and the remainder 41.6% at non-teaching hospitals. The in-hospital mortality of delirium patients in teaching hospitals was 1.33% (95% CI 1.08%-1.63%), and 1.26% (95% CI 0.97%-1.63%) in non-teaching hospitals. The mean total hospital costs were $7642 (95% CI 7384-7900) in teaching hospitals, and $6650 (95% CI 6460-6840) in non-teaching hospitals. After adjustment for confounders, total hospitalization costs were statistically significantly different between the hospitals types-with non-teaching providing less expensive care.

CONCLUSIONS

Patients with delirium admitted to non-teaching hospitals had comparable clinical and process outcomes achieved at lower costs. Further research can be conducted to explore the contextual issues and reasons for these differences in healthcare costs.

Defining Clinical Excellence in Hospital Medicine: A Qualitative Study

INTRODUCTION

There are now more than 50,000 hospitalists working in the United States. Limited empiric research has been performed to characterize clinical excellence in hospital medicine. We conducted a qualitative study to discover elements judged to be most pertinent to excellence in clinical care delivered by hospitalists.

METHODS

The chiefs of hospital medicine at five hospitals were asked to identify their "clinically best" hospitalists. Data collection, in the form of one-on-one interviews, was directed by an interview guide. Interviews were transcribed verbatim, and the informants' perspectives were analyzed using editing analysis to identify themes.

RESULTS

A total of 26 hospitalists were interviewed. The mean age of the physicians was 38 years, 13 (50%) were women, and 16 (62%) were non-white. Seven themes emerged that related to clinical excellence in hospital medicine: communicating effectively, appreciating partnerships and collaboration, having superior clinical judgment, being organized and efficient, connecting with patients, committing to continued growth and development, and being professional and humanistic.

DISCUSSION

This qualitative study describes how respected hospitalists think about excellence in clinical care in hospital medicine. Their perspectives can be used to guide continuing medical education, so that offered programs can pay attention to enhancing the skills of learners so they can develop towards excellence, rather than using only competence as the desired target objective.

Developing a comportment and communication tool for use in hospital medicine

BACKGROUND

An exceptional experience in a hospital is largely influenced by the quality and performance of the hospitalist physician. We set out to establish a metric that would comprehensively assess hospitalists' comportment and communication to establish norms and expectations.

METHODS

The chiefs of hospital medicine divisions at 5 hospitals were asked to identify their "most clinically excellent" hospitalists. An investigator observed each hospitalist during a routine clinical shift and recorded behaviors believed to be associated with excellent comportment and communication using the hospital medicine comportment and communication tool (HMCCOT). Content, internal structure, and relation to other variables validity evidence were established. Analysis of the data for every single patient encounter allowed for the iterative revision of the HMCCOT and the calculation of scores. The mean HMCCOT score of each provider was compared to their Press Ganey (PG) scores.

RESULTS

The mean age of the 26 participating physicians was 38 years, 13 (50%) were female, and 16 (62%) were of nonwhite race. The mean HMCCOT score was 61 (interquartile range = 37-80). HMCCOT score and PG were moderately correlated (adjusted Pearson correlation = 0.45, P = 0.047).

CONCLUSIONS

This study represents a first step to specifically characterize comportment and communication in hospital medicine. Because hospitalists spend only a small proportion of their clinical time in direct patient care, it is imperative that excellent comportment and communication be established as a goal for every encounter. Journal of Hospital Medicine 2015;11:853-858. © 2015 Society of Hospital Medicine.

CEREBELLAR ATAXIA AS A PRESENTING FEATURE OF HYPOTHYROIDISM

Context

Besides its typical features, hypothyroidism comes to notice sometimes with neurologic features like reversible cerebellar ataxia, dementia, peripheral neuropathy, coma, etc. Therefore hypothyroidism should be suspected in all cases of cerebellar ataxia, as it is easily treatable.

Objective

Here we illustrate a case of hypothyroidism initially reported with cerebellar ataxia.

Case report

A 40 year-old male presented with history of gait-ataxia. His investigations revealed frank primary hypothyroidism with positive anti-TPO antibody. The patient was put on thyroxine and he improved completely within eight weeks.

Conclusions

This case report emphasizes that hypothyroidism can present with ataxia as one of the initial features. Therefore, hypothyroidism should be considered in all cases of cerebellar ataxia as it is a reversible cause of ataxia.

Providing Feedback on Clinical Performance to Hospitalists: Experience Using a New Metric Tool to Assess Inpatient Satisfaction With Care From Hospitalists

INTRODUCTION

Physicians have been shown to possess limited ability for accurate self-assessment; thus, effective feedback is crucial for their professional development. This study describes providers' reflections on their data and evaluates the hospitalist physicians' impressions about receiving this feedback derived from a new survey metric specifically designed to obtain patient assessment of their treating hospitalist provider coupled with reflective sessions.

METHODS

Participants were 26 hospitalists from one institution. These physicians' data were used for the development and validation of a new metric, Tool to Assess Inpatient Satisfaction with Care from Hospitalists (TAISCH). Participants received a summary of ratings from patients for whom they were the primary provider. This was followed by a 15-minute semistructured telephone interview to discuss the data. Participants then completed an online survey to assess their perceptions about the data and the efficacy of the feedback. Both quantitative and qualitative results were analyzed.

RESULTS

All 26 providers reviewed their evaluation data, participated in the discussion of results by phone, and completed the online survey. Most (54%) agreed that TAISCH was superior to Hospital Consumer Assessment of Healthcare Providers and Systems in providing hints on how to improve the quality of the care and in providing detailed information about the performance in specific areas (62%). After stratifying hospitalists according to their performance, it was observed that those who scored better responded more favorably to the data. The two main themes that emerged from the qualitative analysis were "reflection on one's performance" and "feedback using TAISCH."

DISCUSSION

Most hospitalists in our study felt that TAISCH provided meaningful feedback.

Comportment and Communication Patterns among Hospitalist Physicians: Insight Gleaned Through Observation

OBJECTIVES

By 2014, there were more than 40,000 hospitalists delivering the majority of inpatient care in US hospitals. No empiric research has characterized hospitalist comportment and communication patterns as they care for patients.

METHODS

The chiefs of hospital medicine at five different hospitals were asked to identify their best hospitalists. These hospitalists were watched during their routine clinical care of patients. An observation tool was developed that focused on elements believed to be associated with excellent comportment and communication. One observer watched the physicians, taking detailed quantitative and qualitative field notes.

RESULTS

A total of 26 hospitalists were shadowed. The mean age of the physicians was 38 years, and their average experience in hospital medicine was 6 years. The hospitalists were observed for a mean of 5 hours, during which time they saw an average of 7 patients (patient encounters observed N = 181). Physicians spent an average of 11 minutes with each patient. There was large variation in the extent to which desirable behaviors were performed. For example, most physicians (76%) started encounters with an open-ended question, and relatively few (30%) attempted to integrate nonmedical content into conversation with patients.

CONCLUSIONS

This study represents a first step in trying to characterize comportment and communication in hospital medicine. Because hospitalists spend only a small proportion of their clinical time in direct patient care, it is imperative that excellent comportment and communication are clearly defined and established as a goal for every encounter.

Development and validation of the tool to assess inpatient satisfaction with care from hospitalists

OBJECTIVES

To develop and validate a new inpatient satisfaction metric to assess patients' perceptions of hospitalist performance.

PATIENTS AND METHODS

We developed the Tool to Assess Inpatient Satisfaction with Care from Hospitalists (TAISCH) by building upon the theoretical underpinnings of the quality of care measures that the Society of Hospital Medicine endorses. TAISCH was completed by inpatients at an academic institution between September 2012 and December 2012 after they had been cared for by the same hospitalist provider for at least 2 consecutive days. Content, internal structure, and convergent/discriminant validity evidence were assessed for TAISCH.

RESULTS

A total of 203 patients each rated 1 of our 29 hospitalists (patient response rate: 88%). Factor analyses resulted in a single factor with 15 items. Reliability of TAISCH was good (Cronbach's α = .88). The hospitalists' average TAISCH score ranged from 3.25 to 4.28 (mean [standard deviation] = 3.82 [0.24]; possible score range: 1-5). The relationship between TAISCH with a validated empathy scale and a global provider satisfaction question revealed significant positive associations (β = 12.2, and β = 11.2 respectively, both P < 0.001). At the provider level, no significant correlation was noted between the Press Ganey Physician score and TAISCH (r = 0.91, P = 0.51).

CONCLUSION

TAISCH collects patient satisfaction data that are attributable to specific hospitalist providers. The timeliness of the TAISCH data collection also makes real-time service recovery possible, which is unachievable with other commonly used patient satisfaction metrics.

Distraction index as a risk factor for osteoarthritis associated with hip dysplasia in four large dog breeds

OBJECTIVE

To determine if age, breed, gender, weight or distraction index (DI) influenced the risk of radiographic osteoarthritis (OA) of canine hip dysplasia (CHD) in four common dog breeds; the American bulldog, Bernese mountain dog, Newfoundland and standard poodle.

MATERIALS AND METHODS

This was a cross sectional prevalence study with 4349 dogs. Canine hips were evaluated using 3 radiographic projections: the hip-extended view, the compression view and the distraction view. The hip-extended view was examined for the presence of OA. The PennHIP distraction view was utilized to calculate the DI. For all breeds, a multiple logistic regression model incorporating age, weight, gender, and DI was created. For each breed, disease-susceptibility curves grouping dogs on the basis of age were constructed. Receiver-operating characteristic (ROC) curves were developed for each breed regardless of age.

RESULTS

For all breeds, DI was the most significant risk factor for the development of OA associated with CHD. Weight and age were also significant risk factors in all four breeds, but gender was not.

CLINICAL SIGNIFICANCE

Results from this study support previous findings, that irrespective of breed, the probability of radiographic OA increases with hip joint laxity as measured by the DI. Breed-specific differences in this relationship, however, warrant investigation of all breeds affected by CHD to determine inherent dependency of hip OA on joint laxity. Such findings guide veterinarians in helping dog breeders to make evidence-based breeding decisions and in informing dog owners to implement preventative treatments for CHD for dogs found to be at risk.

Unenhanced multidetector CT (CT KUB) in the initial imaging of suspected acute renal colic: evaluating a new service

AIM

To evaluate a new imaging pathway for the investigation of patients presenting with suspected acute renal colic.

MATERIALS AND METHODS

A retrospective review of 500 consecutive cases of suspected acute renal colic was undertaken to evaluate the initial results of a new imaging pathway introduced at our institution, which completely replaced the intravenous urogram (IVU) with unenhanced multidetector CT (CT KUB).

RESULTS

The positive rate for urolithiasis was 44% (221/500), the negative rate 46% (229/500) and the rate of other significant findings was 12% (59/500). Female patients had a low positive rate compared with male patients (27.5 versus 57.5%; p<0.001). Urological intervention was required in 28% (61/221) and these patients had a larger average stone size (6.6 versus 3.7 mm; p<0.001) and the stone was located more proximally. Out-of-hours imaging was performed in 37% (186/500), and these patients had a higher positive rate (52 versus 40%; p<0.001). Other findings included a wide range of acute non-urological conditions.

CONCLUSION

The feasibility of replacing the acute IVU with CT KUB in the initial assessment of suspected acute renal colic was demonstrated in the present study. The technique enables rapid diagnosis of urolithiasis, stratification of patients likely to proceed to urological intervention, and prompt diagnosis of a variety of other acute pathological conditions.

Sarcomatoid carcinoma of larynx

Surcomatoid Carcinoma are rare lesions reported in many organs including the larynx. This report describes such a mixed tumour occuring in the larynx. The clinico pathological features and treatment are described.

A rare long standing foreign body in the larynx

An accidentally inhaled foreign body (A metallic toe ring) inside the larynx of a 2 1/2 year old child has been studied. It remained in the larynx for 8 months before detection and removal.

Direct immunoperoxidase test in the diagnosis of rabies--an alternative to fluorescent antibody test

Direct immunoperoxidase test was run parallel to fluorescent antibody test using known rabies-positive and negative materials. Both the tests had 100.0% sensitivity and specificity when mice brain infected with CVS strain of Rabies virus was used. With the field samples and the mice brains infected with these, the sensitivity of direct immunoperoxidase test and also of fluorescent antibody test dropped a little, giving an overall sensitivity of 95.3 and 99.0 percent respectively. The standardization of immunoperoxidase test is described and the results discussed.