ENTEROBACTER CLOACAE CARDIAC IMPLANTABLE ELECTRONIC DEVICE INFECTION.

Enterobacter cloacae cardiac implantable electronic device infections are rare but can be associated with significant morbidity and mortality. We report an 11-year-old female with Enterobacter cloacae infection of a dual-chamber transvenous pacemaker pocket. The report is supplemented by a comprehensive review of the literature on Enterobacter cloacae cardiac implantable electronic device infections.

Case report of probable desert black snake envenomation in 22-year-old male causing profound weakness and respiratory distress.

We describe a case of a 22-year-old male who presented to our facility 1 hour after a snake bite, which he identified as the desert black snake. He presented with severe weakness and respiratory distress. He was treated with polyvalent antivenom and observed in the Intensive Care Unit (ICU) with resolution of his respiratory symptoms. He developed paresthesias locally around his wound and later complained of diplopia. Two days later, he had total resolution of his symptoms. This is one of the only clinical reports of neurotoxic effects after Walterinnesia morgani envenomation.

Necrobacillosis: A case report of complicated Fusobacterium necrophorum septicemia.

Necrobacillosis due to Fusobacterium necrophorum is an uncommon anaerobic infection. It has a wide range of presentations and commonly presents as Lemierre's syndrome. We present a case of necrobacillosis defined by F. necrophorum bacteremia with epidural and pararectal fluid collection without evidence of internal jugular vein thrombophlebitis.

Teaching Diagnostic Reasoning to Faculty Using an Assessment for Learning Tool: Training the Trainer.

Introduction: There is a need for a standardized approach to understand and assess clinical reasoning in medical learners. The Assessment of Reasoning Tool was developed based on prevalent theories and frameworks using a multidisciplinary expert panel. As the tool provides a standardized rubric for assessing clinical reasoning, we designed an interactive train-the-trainer workshop for clinical educators and education leaders interested in improving their teaching skills and/or introducing curricula surrounding diagnostic reasoning. Methods: In this workshop, participants were exposed to the major domains of diagnostic reasoning and how to apply it to the assessment of a learner's skills. Kolb's experiential learning was the underlying model, which we showcased by using multiple interactive techniques, including small-group discussion, peer sharing, and case practice. We presented the workshop at a national conference of pediatric educators and as a faculty development workshop at a single institution. Participants were asked to complete a survey after the workshop to gauge their reactions and look for areas of improvement. Results: A total of 34 participants attended the two workshops. Participants rated the workshop favorably, with most planning to make a change to their practice. Comments were largely positive, emphasizing the benefits of the interactive approach. Discussion: The workshop and teaching materials represent an important early step in the workplace-based assessment of diagnostic reasoning in medical learners. Grounded in the clinical reasoning literature, the workshop offers one approach to assessing these skills in learners with or without direct observation of clinical skills.

Health Maintenance Deficits in a Fully Insured Population of Adolescents With Chronic Medical Conditions.

The current national monitoring of routine wellness care and vaccine uptake does not provide data on health maintenance among pediatric populations with chronic medical conditions. In this case-control study that analyzes wellness visits and vaccine uptake among adolescents, ages 16 to 18 years, we identified 938 without (controls) and 74 with (cases) 1 of 12 specific chronic medical conditions. The PPSV23 (23-valent pneumococcal polysaccharide vaccine) is recommended by the Advisory Committee on Immunization Practices for these 12 conditions and served as a measure of uptake for medically indicated vaccines. Our controls were twice as likely as cases to have a documented well visit in the past year, and there was a significantly higher proportion of controls than cases vaccinated with Tdap (tetanus toxoid, reduced diphtheria toxoid, acellular pertussis), MCV-4 (quadrivalent meningococcal conjugate), and HPV (human papillomavirus), all P < .05. More than 60% of cases failed to receive PPSV23. Adolescents with chronic medical conditions are at high risk of neglecting routine health maintenance.

Infantile Kawasaki disease and peripheral gangrene.

We report a 1-month-old infant with Kawasaki disease and peripheral gangrene. We advocate using the newly published American Heart Association guidelines advising early laboratory and echocardiogram investigations in infants with fever but without other classic manifestations of Kawasaki disease. Initiation of early therapy may prevent this serious complication with its permanent sequelae.

Pertussis pneumonia, hypoxemia, hyperleukocytosis, and pulmonary hypertension: improvement in oxygenation after a double volume exchange transfusion.

A 3-month-old infant of 33 weeks' gestation was hospitalized with pneumonia caused by Bordetella pertussis. Respiratory insufficiency worsened, and on hospital day 3, there was severe pulmonary dysfunction (arterial oxygen pressure/fraction of inspired oxygen ratio: 120), extreme leukocytosis (white blood cell count 104,000/mm3), and severe pulmonary hypertension as assessed by 2-dimensional echocardiogram. A double volume exchange transfusion was performed to reduce the leukocyte mass. Oxygenation began to improve during the exchange and continued to improve over the ensuing 31 hours (arterial oxygen pressure/fraction of inspired oxygen ratio: 280). The white blood cell count fell dramatically after the exchange, and the rate of rise was slower after exchange therapy compared with preexchange.