Locating, characterizing and minimizing sources of error for a paper case-based structured oral examination in a multi-campus clerkship.

OBJECTIVE: To determine consistency of assessment in a new paper case-based structured oral examination in a multi-community pediatrics clerkship, and to identify correctable problems in the administration of examination and assessment process. METHOD: Nine paper case-based oral examinations were audio-taped. From audio-tapes five community coordinators scored examiner behaviors and graded student performance. Correlations among examiner behaviors scores were examined. Graphs identified grading patterns of evaluators. The effect of exam-giving on evaluators was assessed by t-test. Reliability of grades was calculated and the effect of reducing assessment problems was modeled. RESULTS: Exam-givers differed most in their "teaching-guiding" behavior, and this negatively correlated with student grades. Exam reliability was lowered mainly by evaluator differences in leniency and grading pattern; less important was absence of standardization in cases. CONCLUSIONS: While grade reliability was low in early use of the paper case-based oral examination, modeling of plausible effects of training and monitoring for greater uniformity in administration of the examination and assigning scores suggests that more adequate reliabilities can be attained.

Medical evaluation of child abuse.

Child abuse is a world-wide problem and has existed in all societies and cultures in various forms since ancient times. Intrafamilial physical and sexual abuse is well recognized in United States and other western countries. In countries like India there is a general lack of sensitivity to the issue among professionals and the lay public alike. The pressing issues of poverty, malnutrition, and infectious diseases take priority on resource allocation. Although some of the methods of child rearing and discipline may be culturally sanctioned and inherent, it does not necessarily mean they are harmless. In this paper the authors present clinical signs and symptoms of physical and sexual abuse which occur in the intrafamilial context and are of direct relevance to the medical practitioner.

Uses and technique of pediatric lumbar puncture.

OBJECTIVES: To review diagnostic and therapeutic indications, contraindications, complications, and technique of pediatric lumbar puncture with emphasis on diagnosis of bacterial meningitis in bacteremia, cellulitis, and fever with seizures and to discuss cerebrospinal fluid findings in partially treated infection and traumatic blood-contaminated spinal tap. RESEARCH DESIGN: Literature review. CONCLUSIONS: We recommend lumbar puncture for children younger than 1 year with bacteremia, children with Haemophilus influenzae type B cellulitis, and children with fever and seizures not classified as simple. Pretreatment with antibiotics rarely changes cerebrospinal fluid characteristics such that a diagnosis of bacterial meningitis would be obscured. In a traumatic spinal tap, the equation to predict cerebrospinal fluid pleocytosis based on the peripheral blood cell count is invalid. When used together, cerebrospinal fluid glucose level, Gram's staining, and observed-to-expected ratio of white blood cells are highly reliable in diagnosing bacterial meningitis.

Systemic vasculitis associated with eosinophilia and marked degranulation of tissue eosinophils.

A 9-year-old girl had fever, life-threatening interstitial pneumonia, a vesicular skin rash, parotid and submandibular swelling, and marked blood eosinophilia (WBC count 47,000/microL, 39% eosinophils). Results of lung and skin biopsies showed vasculitis with intense eosinophil infiltration. Immunofluorescence analyses of these biopsies, as well as analysis of tissue from the parotid, lip, and trachea, showed striking deposition of eosinophil granule major basic protein associated with areas of tissue damage. Treatment with glucocorticoids and hydroxyurea produced clinical improvement. The association between tissue damage and deposition of the cytotoxic major basic protein suggests that the eosinophil contributed to the pathophysiology of this disease. Recognition of the capacity of the eosinophil to produce tissue damage can be helpful in the selection of therapy.

House staff manuals: a survey of pediatric residency programs.

To determine the role of house staff manuals in residency training, we did a survey of the pediatric residency directors in the United States. Questionnaires were returned from 77% of the programs (179/232). Sixty percent of respondents provided written administrative and medical guidelines to their house staff. Neonatal or pediatric intensive care and emergency protocol information were presented most frequently. Consistent patterns of content and organization were apparent in the 77 manuals reviewed, though style and size varied widely. We conclude that written departmental guidelines are a common and potentially useful educational resource. Evaluation of the effectiveness of manuals to solve patient care or administrative problems is necessary for future refinements in content and format.

Pediatric residency guidelines for management of status epilepticus.

We reviewed 21 protocols for the evaluation and treatment of status epilepticus currently in use in pediatric residency programs. Guidelines were compared to determine variations in the recommendations for initial patient assessment, choice of anticonvulsant therapy, and instructions for medication administration. There was wide variation in recommendations for patient stabilization procedures and laboratory measurements. Fifteen different sequences of anticonvulsant administration were listed. The initial drug of choice was intravenous diazepam in 81% of the programs, in doses ranging from 0.1 to 0.75 mg/kg. The preference for the second-line anticonvulsant was divided equally between phenytoin and phenobarbital. Phenytoin was not mentioned at all in three (14%) of the protocols, while paraldehyde was included in 14 (66%). Instructions for paraldehyde administration were confusing, imprecise, and occasionally inappropriate. We conclude that there is no well-accepted approach to the management of status epilepticus in pediatric patients. Furthermore, the guidelines in current use frequently are incomplete and probably confusing to residents.

Breast milk iodide: reassessment in the 1980s.

In addition to iodized salt, the American diet is inadvertently supplemented with iodine from other foods, such as bread and cow's milk. The iodine content of breast milk has not been assessed recently in this country. Sixty-one samples of breast milk from 37 women were analyzed for iodide content using an iodide-selective electrode method. Mean breast milk iodide level on initial samples for this population was 178 micrograms/L (range 29 to 490 micrograms/L), about four times the recommended daily allowance for infants. Iodide levels in breast milk did not correlate with the age of the infant (ie, stage of lactation). There was a significant correlation between the iodide level in the breast milk and dietary iodine as estimated by a food frequency questionnaire, and iodized salt intake was significantly related to the iodide content of the breast milk.