Exploring formal and informal learning opportunities during morning report: a qualitative study

BACKGROUND

Morning reports are an essential component of physicians' daily work. Attending morning reports is prioritized by junior doctors as it provides them with an opportunity to learn diagnostic reasoning through discussion of cases. While teaching formats during morning reports have previously been reported, an in-depth analysis of what learning opportunities exist, e.g., how teaching is enacted during morning reports, is lacking. This qualitative study explores learning opportunities during morning reports.

METHODS

We used an explorative design based on video-recordings of 23 morning reports from two surgical departments, an internal medicine department and an emergency department. We used thematic analysis combined with and inspired by Eraut's theoretical framework of workplace learning.

RESULTS

Both formal and informal learning opportunities were identified. Formal learning opportunities had the character of planned teaching activities, and we identified four themes: (1) modes of teaching, (2) structure, (3) presenter role, and (4) participant involvement. Informal learning, on the other hand, was often implicit and reactive, while deliberate learning opportunities were rare. The data showed many missed opportunities for learning.

CONCLUSION

Both formal and informal learning opportunities are present during morning reports. However, a prevalent focus on medical topics exists, leaving other important aspects of the medical role under-discussed. Pedagogical methods could be employed more optimally, and harnessing the potential of missed opportunities should be encouraged.

SLC6A1 variant pathogenicity, molecular function and phenotype: a genetic and clinical analysis

Genetic variants in the SLC6A1 gene can cause a broad phenotypic disease spectrum by altering the protein function. Thus, systematically curated clinically relevant genotype-phenotype associations are needed to understand the disease mechanism and improve therapeutic decision-making. We aggregated genetic and clinical data from 172 individuals with likely pathogenic/pathogenic (lp/p) SLC6A1 variants and functional data for 184 variants (14.1% lp/p). Clinical and functional data were available for a subset of 126 individuals. We explored the potential associations of variant positions on the GAT1 3D structure with variant pathogenicity, altered molecular function and phenotype severity using bioinformatic approaches. The GAT1 transmembrane domains 1, 6 and extracellular loop 4 (EL4) were enriched for patient over population variants. Across functionally tested missense variants (n = 156), the spatial proximity from the ligand was associated with loss-of-function in the GAT1 transporter activity. For variants with complete loss of in vitro GABA uptake, we found a 4.6-fold enrichment in patients having severe disease versus non-severe disease (P = 2.9 × 10-3, 95% confidence interval: 1.5-15.3). In summary, we delineated associations between the 3D structure and variant pathogenicity, variant function and phenotype in SLC6A1-related disorders. This knowledge supports biology-informed variant interpretation and research on GAT1 function. All our data can be interactively explored in the SLC6A1 portal (https://slc6a1-portal.broadinstitute.org/).

Co-regulation of learning in a department of paediatrics

INTRODUCTION

Co-regulated learning (CRL) is a process in which the learner's regulation of learning is guided by social transactions. The change in learning techniques during the transition from university to workplace learning and the rapidly changing learning environment make awareness of CRL extremely relevant. This study examined CRL among medical students and residents and identified the factors affecting CRL.

METHODS

We applied an explorative approach using direct observation and semi-structured focus group discussions (FGD). The first author made direct observations that produced explorative data about actual behaviour. However, this was not sufficiently sensitive to capture the participants' full perceptions of CRL. Therefore, we conducted semi-structured FGD that involved interactions and reflections among the participants.

RESULTS

This study suggests that CRL occurred in multiple situations and was affected by many factors. The stimulating factors identified were a supportive learning environment, feedback based on observations and questioning by a supervisor, dyad work and interactive, bimodal presentation of emergency cases at the morning conference. Time pressure, heavy workload and shortage of specialists were inhibiting factors.

CONCLUSION

We identified several factors affecting CRL. A focus on the augmentation of stimulating factors and reduction of inhibiting factors may help medical students and residents develop CRL.

FUNDING

None.

TRIAL REGISTRATION

Not relevant.

How doctors build community and socialize into a clinical department through morning reports. A positioning theory study

PHENOMENON

The morning report is one of the longest surviving hospital practices. Most studies of the morning report focus on the effectiveness of formal medical training, while focus on social and communicative aspects is rarer. This study explores the social interactions and communication in morning reports, examining the ways in which they contribute to the construction of professional identity and socialization into the community of the clinical department.

APPROACH

We used a qualitative explorative design with video observations of morning reports. Our data consisted of 43 video-recorded observations (in all, 15.5 hours) from four different hospital departments in Denmark. These were analyzed using the theoretical framework of positioning theory.

FINDINGS

A key finding was that each department followed its own individual structure. This order was not articulated as such but played out implictly. Two alternative storylines unfolded in the elements of the morning report: 1) being equal members of the specialty and department, and 2) preserving the hierarchical community and its inherent positions.

INSIGHTS

The morning report can be seen as playing an important role in community making. It unfolds as a "dance" of repeated elements in a complex collegial space. Within this complexity, the morning report is a space for positioning oneself and others as a collegial "we", i.e., equal members of a department and specialty, at the same time as "having a place" in a hierarchal community. Thus, morning reports contribute to developing professional identity and socialization into the medical community.

Splenic Abscess in an Adolescent due to Salmonella enterica Conservatively Treated with Ultrasound-Guided Fine-Needle Aspiration

Background

Splenic abscesses are rare and potentially fatal. Diagnosis is often delayed due to vague symptoms, and laboratory findings are varying and often nonspecific. Ultrasound and computed tomography have a high sensitivity in detecting splenic abscesses. Splenectomy was previously considered the gold standard for treatment, but in recent years, a shift has been seen towards a more conservative approach, i.e., ultrasound-guided aspiration or drainage in combination with adequate antibiotics in selected cases. Case Report. A previously healthy adolescent complained of left-sided chest pain, pain in the left clavicular region for three weeks, and recent fever. Ultrasound and computed tomography demonstrated an intrasplenic abscess. The patient was successfully treated with two percutaneous fine-needle punctures and adequate antibiotics for six weeks. Salmonella enterica serotype Poona was grown from the aspirate. At one-year follow-up, the patient remained healthy without signs of recurrence.

Conclusion

The present case report demonstrates that ultrasound-guided aspiration and subsequent treatment with antibiotics may be an effective alternative to splenectomy in patients with a splenic abscess.

How isolation of key information and allowing clarifying questions may improve information quality and diagnostic accuracy at case handover in paediatrics

Handover between colleagues is a complex task. The problem is that handovers are often inadequate because they are not structured according to theoretically grounded guidelines. Based on the cognitive load theory, we suggest that allowing a clarifying dialogue and thereby optimizing germane cognitive load enhances the information quality and diagnostic accuracy at handover, but may prolong handover duration. We also expect that mentioning key information first and thus decreasing intrinsic cognitive load improves information quality and diagnostic accuracy. We developed two representative paediatric cases for presentation in a factorial 2 × 2 design. Sixth-year medical students (N = 80) were randomly assigned to one of four groups that differed with regard to how the case histories were delivered to them (chronological order versus key information mentioned first) and direction of information exchange (unidirectional versus a clarifying dialogue). The receivers of the handover were asked to write a report of the cases and suggest the best diagnosis. Dependent variables were information quality of the written report (Information score), quality of the diagnosis (Diagnostic accuracy score) and the time it took to deliver the written handover case report (Handover report duration). Seen through the lens of cognitive load theory, allowing a clarifying dialogue at handover, and thus optimizing the germane cognitive load, significantly increased the Information score (p < 0.0005), Diagnostic accuracy score (< 0.05) and Handover report duration (p < 0.001).

[Functional disorders in previously healthy children during the COVID-19 pandemic]

Functional disorders may involve neurological symptoms, which are triggered by stressful situations. This case report describes two otherwise healthy children with sudden onset of functional symptoms in the days preceding the reopening of their schools after a suspension due to the COVID-19 pandemic outbreak. Little treatment was necessary, and both patients made fast recoveries. We correlate these symptoms with the stress associated with the COVID-19 pandemic and the suspension of normal education.

Identifying and prioritising technical procedures for simulation-based curriculum in paediatrics: a Delphi-based general needs assessment

OBJECTIVES

To identify and prioritise technical procedures that should be integrated in a curriculum of simulation-based procedural training in paediatrics using the Delphi method.

STUDY DESIGN

National general needs assessment using a Delphi process was completed among 93 key opinion leaders in paediatrics in Denmark. Delphi round 1 identified technical procedures. Round 2 explored frequency of procedures, number of paediatricians performing the procedures, risks and/or discomfort for patients and feasibility for simulation-based training. Round 3 included final elimination and reprioritisation.

RESULTS

Response rates in the Delphi rounds were 73%, 71% and 72%. We identified 37 procedures in Delphi round 1, preprioritised in round 2, resulting in a final list of 19 procedures in round 3. Strong correlation between the prioritisation from the second and third Delphi rounds was identified, Spearman's r of 0.94 (p<0.0001). Top five on the final list were acute neonatal airway management, acute non-neonatal airway management, non-neonatal peripheral intravenous and intraosseous access, neonatal vascular access and advanced heart lung resuscitation.

CONCLUSION

We identified and prioritised 19 technical procedures in paediatrics that are suitable for simulation and may be used as a guide for the development of simulation-based curriculum in paediatrics.

Selection and ranking of patient video cases in paediatric neurology in relation to learner levels

BACKGROUND

Teaching and learning with patient video cases may add authenticity, enhance diagnostic accuracy and improve chances of early diagnosis. The aim of this study is firstly to identify selection criteria for key Patient video cases (PVCs), secondly to identify trends in relevance of PVCs for learner levels and thirdly, to rank PVCs for learner levels.

METHODS

Based on a literature review, we identified criteria for key PVCs for use in paediatric neurology. We then performed a multi-round Delphi analysis to obtain agreement between 28 expert clinician teachers concerning key PVCs for four learner levels.

RESULTS

We identified two major criteria: key PVCs should demonstrate key movements, and these movements should be subtle and/or difficult to note. The expert clinician teachers subsequently assessed a list of 14 topics for key PVCs. We found a clear, increasing trend in relevance scores, from medical students to young residents to experienced residents and specialists. For medical students and residents, epileptic spasms, Down syndrome, developmental delay, cerebral palsy and absence epilepsy were highly ranked. For specialists, conditions like chorea, focal seizures or eye movement disorders topped the ranking list, although ranking was less clear for this group of advanced learners.

DISCUSSION AND CONCLUSION

Key PVCs should demonstrate movements that are difficult to note for learners. Ranked lists of key PVCs for teaching and learning at different learner levels are now available and may help institutions build validated local libraries of PVCs.

The Child Health System in Denmark: Current Problems and Successes

In Denmark, child primary care is taken care of by general practitioners who have 6 months of pediatric training as part of their specialty training and, therefore, are qualified to work as gatekeepers for the secondary health care at the hospitals. As new, more expensive, drugs are increasingly prescribed, corresponding expenses pose serious threats to the economy at 18 pediatric departments. We will highlight the new developments in pediatric education: skills training and training of clinical reasoning.

[Intervertebral discitis in children]

Intervertebral discitis is a rare disorder which is easily missed. It presents with non-specific symptoms such as irritability, abdominal pain, decreased appetite and limping. The infection parameters can be normal, and blood cultures are often negative. The pathogenesis is not established but infectious, and inflammatory aetiologies have been suggested. Diagnostic golden standard is magnetic resonance imaging. The treatment is immobilization, anti-inflammatory drugs and often antibiotics. Early treatment is important to reduce the risk of complications such as nerve damage and spine fusion.

[Arthrogryposis multiplex congenita]

Arthrogryposis multiplex congenita (AMC) is a sign rather than a diagnosis. It implies contractures in multiple body areas and occurs in 1:3,000-5,000 live births. Primary aetiologies include neuropathic, myopathic, metabolic, end plate and vascular disorder affecting the developing foetus, including limitation of foetal space. Amyoplasia is the most common type of AMC after central nervous system disorders. Knowledge about the classification of AMC is essential to make a correct diagnosis and treatment plans. We recommend follow-up by experienced paediatric orthopaedic surgeons and neurologists.

Combining bimodal presentation schemes and buzz groups improves clinical reasoning and learning at morning report

Morning reports offer opportunities for intensive work-based learning. In this controlled study, we measured learning processes and outcomes with the report of paediatric emergency room patients. Twelve specialists and 12 residents were randomised into four groups and discussed the same two paediatric cases. The groups differed in their presentation modality (verbal only vs. verbal + text) and the use of buzz groups (with vs. without). The verbal interactions were analysed for clinical reasoning processes. Perceptions of learning and judgment of learning were reported in a questionnaire. Diagnostic accuracy was assessed by a 20-item multiple-choice test. Combined bimodal presentation and buzz groups increased the odds ratio of clinical reasoning to occur in the discussion of cases by a factor of 1.90 (p = 0.013), indicating superior reasoning for buzz groups working with bimodal materials. For specialists, a positive effect of bimodal presentation was found on perceptions of learning (p < 0.05), and for residents, a positive effect of buzz groups was found on judgment of learning (p < 0.005). A positive effect of bimodal presentation on diagnostic accuracy was noted in the specialists (p < 0.05). Combined bimodal presentation and buzz group discussion of emergency cases improves clinicians' clinical reasoning and learning.

Use of patient video cases in medical education

Patient video cases (PVCs) are brief video recordings of patients during spontaneous or instructed activity. PVCs are true to life and can be replayed, enabling the establishment of highly interactive, contextual and safe learning environments, with a minimum of facilitation. This article describes the use of workshops in which PVCs are used to assist with the development of observational skills and clinical reasoning in medical students and postgraduates. We describe why PVCs are a valuable addition to an educator's portfolio of resources, what evidence there is for their effectiveness, how to use videos for teaching, and some practical advice and tips on their collection and storage.

Arterial ischemic stroke as a complication to disseminated infection with Fusobacterium necrophorum

Lemierre syndrome (LS) is a rare complication of oropharyngeal and odontogenic infections in otherwise healthy young individuals. It is characterized by septic internal jugular vein thrombophlebitis and disseminated metastatic abscesses. Cerebral arterial ischemic stroke is rarely seen in LS. The authors present a 14-year-old, previously healthy girl, who developed cerebral arterial infarction following acute tonsillitis and abscess formations due to Fusobacterium necrophorum.

[The 180 degree study is a simple examination of the motor development of infants]

In this article we present The 180 degree study, a systematic and simple approach to examination of the motor development in infants aged 2-10 month. The examination is simple to learn, easy to practice and gives rich opportunity to generate diagnostic hypotheses.

[Multiple mini interviews before the occupation of main training posts in paediatrics]

Interviews are mandatory in Denmark when selecting doctors for training positions. We used multiple mini interviews (MMI) at four recruitment rounds for the main training posts in paediatrics. In total, 125 candidates were evaluated and assessed by CV and MMI (4-5 stations). Reliability for individual stations in MMI assessed by Cronbach's alpha was adequate (0.63-0.92). The overall reliability assessed by G-theory was lower, suggesting that different skills were tested. The acceptability was high. Our experiences with MMI suggest good feasibility and reliability. An increasing number of stations may improve the overall reliability.

Learning to diagnose using patient video case in paediatrics: perceptive and cognitive processes

Thomas Balslev, a paediatric neurologist and educational researcher, defended his thesis on 24 November 2011. The thesis included five published papers, and investigated learning with authentic, brief patient video cases. With analysis of a video case in a small group, learning processes and sharing of knowledge was intensely stimulated. Small group discussion and subsequent listening to an expert's think-aloud were particularly effective approaches to enhance diagnostic accuracy among non-experts. In a descriptive study, expertise-related differences during analysis of patient video cases were characterized, and in a controlled study, different types of visual modelling were tested.

Visual expertise in paediatric neurology

BACKGROUND

Visual expertise relies on perceptive as well as cognitive processes. At present, knowledge of these processes when diagnosing clinical cases mainly stems from studies with still pictures. In contrast, patient video cases constitute a dynamic diagnostic challenge that may simulate seeing and diagnosing a patient in person.

AIMS

This study investigates visual attention and the concomitant cognitive processes of clinicians diagnosing authentic paediatric video cases.

METHODS

A total of 43 clinicians with varying levels of expertise took part in this cross-sectional study. They diagnosed four brief video recordings of children: two with seizures and two with disorders imitating seizures. We used eye tracking to investigate time looking at relevant areas in the video cases and a concurrent think-aloud procedure to explore the associated clinical reasoning processes.

RESULTS

More experienced clinicians were more accurate in visual diagnosis and spent more of their time looking at relevant areas. At the same time, they explored data less, yet they built and evaluated more diagnostic hypotheses.

CONCLUSIONS

Clinicians of varying expertise analyse patient video cases differently. Clinical teachers should take these differences into account when optimising educational formats with patient video cases.

Growth hormone treatment, final height, insulin-like growth factors, ghrelin, and adiponectin in four siblings with Seckel syndrome

OBJECTIVE

To report on the effect of growth hormone (GH) treatment on final height (FH) and to describe the insulin-like growth factor (IGF) system, ghrelin, and adiponectin (ADPN) in children with Seckel syndrome.

SUBJECTS AND RESULTS

Four severely growth-retarded Iraqi siblings (two girls and two boys) with Seckel syndrome were referred at ages 16.5, 14.4, 12.4, and 10.4 years. They were born at term, but their growth was retarded and birth weight ranged between 1 and 1.5 kg. The children were healthy and had a normal response to GH provocative test. Long-term GH treatment of the youngest brother and sister increased the FH by 7.2 and 3.4 cm, respectively, compared with their older brother and sister. At FH, body mass index standard deviation scores (BMISDS) ranged from -3.0 to -3.9. Serum levels of immunoreactive IGF-1, bioactive IGF-1, and IGF-binding protein 3 were all within normal to high range before GH treatment and increased after GH treatment. Fasting plasma ghrelin remained severely reduced. Despite low BMISDS, plasma ADPN was moderately reduced and showed an almost complete absence of the low-molecular-weight subform.

CONCLUSION

This is the first report on the effect of GH treatment on FH in children with Seckel syndrome. GH may have increased FH. In addition to growth defects and reduced BMISDS, patients with Seckel syndrome are characterized by low fasting ghrelin levels, low total ADPN, and near deficiency of the low-molecular-weight ADPN subform. The possible significance of the hormonal changes requires further investigations.

Enhancing diagnostic accuracy among nonexperts through use of video cases

OBJECTIVE

The goal was to determine whether the diagnostic accuracy of nonexperts in selected learning environments would improve with the use of patient video cases (PVCs).

METHODS

We designed a stepwise, team-based, learning approach with a (1) text-based patient presentation, (2) first review of a PVC, (3) small-group discussion, (4) second review of a PVC, and (5) large-group discussion and listening to think-aloud modeling by a content expert. Four pediatric neurology PVCs were analyzed by 44 physicians. After each step, the diagnostic accuracy was assessed with a questionnaire with open-ended questions measuring the frequency of relevant diagnoses and clinical diagnostic reasoning processes.

RESULTS

The first review of the PVC was followed by a large number of relevant clinical diagnostic reasoning processes. Small-group discussions and listening to a think-aloud procedure with an expert were particularly effective in increasing the diagnostic accuracy of the nonexperts.

CONCLUSIONS

The diagnostic accuracy of nonexperts was clearly enhanced by interaction in small-group discussions and subsequent listening to a think-aloud procedure with a content expert. Learning through PVCs in clinical settings thus is improved through the interactive participation of junior and senior clinicians. Such an environment (a "virtual examination room") may be introduced at grand rounds, case conferences, or morning rounds, to stimulate the development of diagnostic accuracy in nonexperts.

The development of shared cognition in paediatric residents analysing a patient video versus a paper patient case

In a previous study, we established that compared to a written case, a video case enhances observable cognitive processes in the verbal interaction in a postgraduate problem-based learning format. In a new study we examined non-observable cognitive processes using a stimulated recall procedure alongside a reanalysis of the data from the first study. We examined the development of shared cognition as reflected in collaborative concept link formation, an approach to connecting a series of concepts related to a particular topic. Eleven paediatric residents were randomly allocated to two groups. After both analysing the same written case vignette, one group watched a video of the case in the vignette and the other group read a written description of the video. Both groups then reanalysed the vignette. After the group sessions, time-logged transcripts were made of the verbal interaction in both groups and all residents individually took part in a stimulated recall procedure. Causal reasoning concept links were labelled as individual or collaborative depending on whether they originated from individual residents or were directly elicited by verbal utterances from others. The video led to a significantly increased frequency ratio (after intervention: before intervention) of collaborative concept links but did not affect the frequency of individual concept links. This novel process approach to chronological registration of concept link formation offered additional evidence that shared cognition by means of co-elaboration of concept formation is stimulated by the use of patient video recordings in small group learning.

[Ten practical, theory-based tips for clinical course planners]

A list of practical advice and examples are given based on the literature. E-learning with cliffhanger text-cases can activate prior knowledge, and selected examination skills can be trained with simulated patients. Patient video recordings can be used to train clinical reasoning skills, including pattern recognition and hypothetic-deductive approaches. Interactive approaches, for example, questioning, quizzes or buzz groups imply active involvement and participation. Quizzes and MCQ-testing can provide a formative 'check-up' on learning and point to gaps in understanding for the teachers and the participants. Spacing a course with intervening assignments can enable the transfer of skills to practice.

[Progressive muscular atrophy in a ten-year-old girl]

Chronic inflammatory demyelinating polyneuropathy, CIDP, is a rare differential diagnosis to the hereditary myopathies but because it can be treated effectively it is important to consider. A ten-year-old girl's proximal muscle groups debilitated progressively, and in four months she lost the ability to walk. Stretch reflexes were absent, creatine kinase low and spinal protein elevated. Muscle biopsy showed demyelinating atrophy. CIDP was diagnosed and she was successfully treated with immunoglobulin.

[Sydenham's chorea, rare but not eradicated]

Sydenham's Chorea (SC), a major manifestation of acute Rheumatic Fever (RF), is a nonsuppurative sequelae of group A streptococcal infection. RF is a significant public health problem in developing countries, and SC continues to afflict large numbers of children throughout the world. Although the incidence of RF is low in industrialized countries, SC does occur. We recently treated two children with SC. Both children showed the typical features of SC, which are choreatic movements, hypotonia and emotional lability. We describe the course of SC in the two children.

[Sydenham's chorea]

Sydenham's Chorea (SC), a major manifestation of acute Rheumatic Fever, is an important cause of acquired chorea in childhood. The disorder is characterized by chorea, muscular weakness and a number of neuropsychiatric symptoms. The diagnosis of SC is based on clinical observation. There have been no double-blind, randomized studies to evaluate the symptomatic treatment of SC.

Comparison of text and video cases in a postgraduate problem-based learning format

OBJECTIVE

To investigate whether adding a brief video case instead of an equivalent written text improves the cognitive and metacognitive processes (data exploration, theory building, theory evaluation and metareasoning) of residents in problem-based learning.

SUBJECTS

Paediatric residents.

SETTING

Department of Paediatrics, Arhus University Hospital, Skejby, Denmark.

METHODS

Eleven residents were each assigned to 1 of 2 groups. Both groups analysed an identical vignette of a patient case. Immediately after this, 1 group watched a 2.5-minute video recording and the other group read a description of the same video recording. The groups then reanalysed the case. Thinking processes were tapped by recording and analysing the verbal group interaction. The frequencies of clause categories were calculated and compared using chi-square tests.

RESULTS

The verbal interaction showed statistically significant improvements in data exploration, theory building and theory evaluation after the video case.

CONCLUSIONS

The greater improvement in clause frequency after the video case compared with the equivalent text suggests an improvement in data exploration, theory building and theory evaluation. The use of patient video recordings may be a valuable supplement to postgraduate paediatric training, particularly pertaining to movement disorders.

POLGmutations in Alpers syndrome

Described are six patients with Alpers syndrome from four unrelated families. Affected individuals harbored the following combinations of POLG mutations: 1) A467T/W1020X, 2) W748S-E1143G/G848S, 3) A467T/A467T, and 4) A467T/G848S. Homozygosity for the A467T allele in one patient was associated with a later age at onset. Mitochondrial respiratory chain studies in skeletal muscle were normal in each case. Nine combinations of mutant POLG alleles that cause Alpers syndrome are summarized.

[MR scanning of cerebrum in the investigation of delayed development in children. Syntelencephaly--is it really so rare?]

A 14-month-old boy presented with a mild global developmental delay, plagiocephaly, and a mild mid-face dysmorphology, including hypertelorism. At 24 months of age, early signs of a spastic diplegic cerebral palsy were noted. MRI of the brain showed middle interhemispheric fusion: syntelencephaly.

Craniofacial morphology, dentition, and skeletal maturity in four siblings with Seckel syndrome

OBJECTIVE

To describe the craniofacial morphology, dentition, and hand maturity in four siblings with Seckel syndrome.

PATIENTS

Two boys and two girls, with Seckel syndrome. The children studied showed extreme growth retardation, severe microcephaly, bird-headed profile with receding chin, prominent nose, mental retardation, and extremely delayed skeletal maturation. The growth hormone axis and pituitary thyroid function was normal.

METHODS

Skeletal and dental development were investigated from radiographic material, and a cephalometric analysis was performed from profile radiographs.

RESULTS

The craniums were remarkably small with an extremely short anterior cranial base (-4.3 to -5.5 standard units) and maxillary length (-3.8 to -4.7 SU). Differences in the morphology of the sella turcica were observed in girls and boys. Tooth maturity progressed normally. Tooth agenesis and tooth malformations were observed. Taurodontic root morphology was observed only in the girls. The approximate skeletal maturity showed retardation from 4 years 3 months to 4 years 11 months. Malformations of the hand-wrist skeleton occurred in the epiphyseal ossification centers of the middle phalangeal bone in the second, third, and fourth finger and in the distal phalangeal bone in the fifth finger. The epiphyseal ossification centers were lacking in the middle and distal phalangeal bones of the fifth finger.

CONCLUSION

The underlying gene defect in the affected children seemingly affects bone development and growth but not dental maturation and eruption.

[Very severe spinal muscular atrophy--type 0. A cause of congenital multiple arthrogryposis]

A female infant born at term, with reduced fetal movements in utero, congenital multiple contractures, severe weakness at birth, and a short time of survival is described. The diagnosis was confirmed by identification of homozygous deletion of exons 7 and 8 of the SMNt gene. Severe spinal muscular atrophy should be considered in the differential diagnosis of reduced fetal movements.

A new locus for Seckel syndrome on chromosome 18p11.31-q11.2

Seckel syndrome (MIM 210600) is a rare autosomal recessive disorder with a heterogeneous appearance. Key features are growth retardation, microcephaly with mental retardation, and a characteristic 'bird-headed' facial appearance. We have performed a genome-wide linkage scan in a consanguineous family of Iraqi descent. By homozygosity mapping a new locus for the syndrome was assigned to a approximately 30 cM interval between markers D18S78 and D18S866 with a maximum multipoint lod score of 3.1, corresponding to a trans-centromeric region on chromosome 18p11.31-q11.2. This second locus for Seckel syndrome demonstrates genetic heterogeneity and brings us a step further towards molecular genetic delineation of this heterogeneous condition.

Removal of 10-hydroxycarbazepine by plasmapheresis

Removal of the oxcarbazepine metabolite 10-hydroxycarbazepine (MHD) by plasmapheresis was evaluated during a series of six plasmaphereses of a 13-year-old boy with Rasmussen encephalitis. Plasmapheresis was performed after steady-state concentrations of MHD had been achieved with a dose of 2550 mg oxcarbazepine daily. The mean amount of MHD removed per plasmapheresis was 78.9 mg (SD: 6.0 mg), representing 3% to 4% of the daily oxcarbazepine dose and approximately 5% to 6% of body stores of MHD. The mean steady-state trough MHD concentration was 33.3 mg/L (SD: 1.8 mg/L), and this was remarkably stable during the entire plasmapheresis period. The serum concentration of MHD was only mildly reduced by the procedure. The areas under the concentration curve of MHD on the first and sixth day of plasmapheresis were 99% and 94%, respectively, of the pre-plasmapheresis values. The results are in agreement with studies on other anticonvulsant medications (carbamazepine, valproic acid, phenobarbital, and phenytoin), indicating that minor fractions (2% to 10%) of body stores of these drugs are depleted during plasmapheresis. The authors conclude that it is unnecessary to adjust the oxcarbazepine dosage when performing single-volume plasma exchanges or even multiple exchanges during an extended period. It is further proposed that plasmapheresis is unlikely to be of therapeutic benefit in the treatment of an oxcarbazepine overdose.

[The objective structured clinical examination in postgraduate pediatric training. The first Danish experiences]

To evaluate the usefulness of an objective structured clinical examination (OSCE) for identifying weaknesses of the educational program and for providing feedback to trainees in paediatrics an 8-station OSCE was given. Ten residents on different levels of training participated. Stations covered a wide spectrum of clinical situations and included three video-recordings of patients. Skills in history-taking, examination, listing of differential diagnoses, planning of work-up as well as in communication and counselling were assessed. Verbal as well as written feedback was provided to all the trainees. In five trainees skills in examination were relatively weak, and subsequently it was possible to implement improvements in the educational program. Strengths and weaknesses of the educational program can be identified, but the benefits of the OSCE should be balanced with the extra workload and logistical difficulties.

Provocation of non-convulsive status epilepticus by tiagabine in three adolescent patients

Three girls, two aged 12 years and one aged 17 years with refractory localization-related epilepsy were treated on an add-on basis with tiagabine. At dosages 22.5-30 mg/day (0.45-0.57 mg/kg/day) longstanding non-convulsive status epilepticus was noted in all three patients. The events of non-convulsive status epilepticus subsided following reduction in tiagabine dosages. In two cases, tiagabine was withdrawn, whereas it was continued at a lower dosage in one case. This is the first report of non-convulsive status epilepticus provoked by tiagabine in adolescent patients.

Van der Knaap's vacuolating leukoencephalopathy: two additional cases

We present two new cases with infantile-onset megalencephaly and a characteristic magnetic resonance imaging (MRI) pattern including severe white-matter abnormalities and subcortical cysts. In one of the patients MRI at the early age of 9 months showed pronounced white matter swelling. In another patient the swelling of white matter was less pronounced at 12 years of age.

[Benign paroxysmal torticollis. Recurrent involuntary twisting of the head in infants and young children]

Benign paroxysmal torticollis occurs in infancy and early childhood. The etiology is unknown, although a vasomotor labyrinthine pathophysiology is possible. We report four cases with onset at ages of two to six months of recurrent episodes of torticollis and discomfort persisting between three hours and seven days. In three cases the torticollis was alternating. Photography or videorecording made by the parents during the attacks were helpful for the diagnosis in three cases. MRI may in some cases be necessary to rule out a space occupying lesion in the posterior fossa.

Congenital cytoplasmic body myopathy with survival motor neuron gene deletion or Werdnig-Hoffmann disease

A 5-week-old boy became rigid and developed cardiac arrest after receiving succinylcholine. He was resuscitated and ventilated but died at 5 months. Muscle biopsy demonstrated no neurogenic features and numerous cytoplasmic bodies, suggesting the possibility of congenital myopathy with cytoplasmic bodies. However, molecular analysis revealed a homozygous deletion of exons 7 and 8 of the survival motor neuron (SMN) gene, suggesting that the patient had Werdnig-Hoffmann disease. We recommend that every patient with congenital cytoplasmic body myopathy be tested for SMN gene deletion.

Infant botulism. The first culture-confirmed Danish case

Infant botulism is caused by intestinal colonization by Clostridium botulinum, C. barati or C. butyricum. Infant botulism has only rarely been reported outside the USA. A 3-month-old boy developed constipation, lethargy, feeding difficulties and descending, severe, symmetric weakness. He was breastfed but had also been fed honey. Supportive care led to complete recovery. The serum was positive for C. botulinum toxin type A-F (mouse toxin neutralization assay). A strain of C. botulinum producing toxin type A and E was identified in the stool. C. botulinum was identified in a jar of honey of the same brand as the honey fed to the patient.

Recurrent seizures in metachromatic leukodystrophy

The unusual presentation of juvenile onset metachromatic leukodystrophy (MLD) and frequent complex partial seizures in a patient led us to perform a retrospective study of 18 patients with MLD to identify the prevalence and type of recurrent seizures during the first 2 years of the disease. Five of 17 patients (29%) had developed recurrent seizures within 12 months of the onset of symptoms, and one patient was lost to follow-up. By 24 months after onset of symptoms, 5 patients were lost to follow-up, and 6 of the remaining 13 patients (46%) had developed recurrent seizures. In all, 7 patients, 4 with late infantile-onset and 3 with juvenile-onset disease, developed recurrent seizures. Four patients, including 3 with juvenile-onset disease had complex partial seizures. We conclude that recurrent seizures are common in MLD and may occur at any stage of the disease, particularly in patients with juvenile onset. Generalized seizures are more frequent in patients with late infantile-onset, whereas partial seizures are more common in those with juvenile-onset disease.

[Withdrawal of antiepileptic treatment]

A review is presented of factors influencing the prognosis for remaining free of seizures after withdrawal of anti-epileptic drugs. Adverse factors are found to be: a) being 16 years or older; b) having had many seizures after starting anti-epileptic drug treatment; c) a history of myoclonic seizures; d) a history of generalised tonic-clonic seizures; e) polytherapy; and f) spike and wave paroxysms in the EEG. An EEG before withdrawal of antiepileptic drugs is only required in patients with primary generalised epilepsy. The social situation and individual wishes of the patient and relatives should be considered when withdrawal of anti-epileptic drugs is being planned. Continued treatment until the patient has remained seizure-free for five years will decrease the risk of relapse. In children, anti-epileptic drugs may be withdrawn after three years of treatment, if no adverse factors are present. Nothing definite is known concerning the withdrawal procedure. A stepwise, slow withdrawal with a duration of six months or more is recommended, as this reduces the risk of relapse.

[Subcutaneous fat necrosis with hypercalcemia]

A case of subcutaneous fat necrosis (SFN) is presented. The infant developed late onset hypercalcaemia of severe degree. Calcitonin failed to normalize the hypercalcaemia. Glucocorticoids and withdrawal of dietary calcium and vitamin D are the treatment of choice. Like hypercalcaemia in association with other granulomatous diseases, SFN is possibly secondary to locally produced 1,25-dihydroxy-cholecalciferol. Our results were not able to confirm this theory. Infants with SFN should have calcium levels monitored closely for months.

[Gentamycin resistant Enterobacteriaceae at a neonatal care unit]

A case of septicaemia in a seven-day-old infant with a gentamicin-resistant strain of Enterobacter cloacae prompted an epidemiological survey in a neonatal unit. Another 18 patients harboured gentamicin-resistant Enterobacteriaceae without symptoms. Control of the outbreak was achieved by cohort nursing, strict hygiene and reduction of aminoglycoside consumption by 50%. Efficiency of the measures was monitored by weekly faecal samples from all patients. All strains produced the aminoglycoside modifying enzyme AAC(3)II. The resistance was plasmid-mediated.

The rôle of ultrasound scan in childhood ovarian tumors

Seven cases with childhood ovarian tumors are presented. All underwent an ultrasound scan which gave the the preliminary diagnosis of ovarian tumor. Treatment differs according to the status of the child and whether malignity is involved. The numerous differential diagnoses must be kept in mind. The management of children with an unexplained abdominal mass should include an ultrasound scan.