Wernicke encephalopathy in nonalcoholic patients.

BACKGROUND: Wernicke encephalopathy is associated with patients that have a history of alcohol abuse and other malnourished states. However, clinicians may be less likely to recognize this condition in nonalcoholic patients. This study was undertaken to evaluate the cause, diagnosis, treatment, and outcome of nonalcoholic patients with Wernicke encephalopathy. METHODS: A retrospective review was conducted of all cases of Wernicke disease from 1984 to 1999 evaluated at a rural university hospital. Inclusion criteria consisted of patients diagnosed clinically with this disorder who improved after the administration of thiamin. Patients were also included in the series if they had classic pathologic findings of the disease on autopsy even without a prior clinical diagnosis. RESULTS: Twelve patients were identified. Alcohol abuse was noted in only 50%. The patients without a history of alcohol abuse had other malnourished states, such as end-stage cancer, intractable vomiting after gastric reduction procedure, and prolonged hospital courses on intravenous fluids without other sources of nutrition. The mortality rate was 4 of 12 (33%) but due to multiple causes. Autopsies were performed on all 4 patients. Three of these 4 patients had no history of alcohol abuse. Two of the nonalcoholic patients were not diagnosed until autopsy, whereas all the patients with a history of alcohol abuse were diagnosed clinically. DISCUSSION: Our study reveals that Wernicke encephalopathy continues to be a rare but life-threatening condition often overlooked in the nonalcoholic population, resulting in the further progression of an easily treatable condition.

Prevalence of pollen sensitization in younger children who have asthma.

It is commonly believed that young children are incapable of pollen sensitization; therefore, skin testing usually is not performed to these allergens. The purpose of this study was to identify the frequency of positive skin tests to outdoor allergens among younger children who have asthma. Patients who have asthma, aged 6 months to 10 years, were evaluated for pollen sensitization over a 10-year period. Skin-prick testing was performed to relevant individual aeroallergens including trees, grasses, and weeds. Testing for perennial indoor allergens such as dust mites, cats, dogs, cockroaches, and molds was performed also. A total of 687 children with asthma were evaluated. No child <12 months old was sensitized to pollens. Children between 12 and 24 months of age had a 29% incidence of pollen sensitization. Three-year-old children were as likely to be skin test positive to pollen as an indoor allergen. Notably, 49% of 3- and 4-year olds were sensitized to outdoor allergens. Primary sensitizing pollens in this age group were short ragweed, box elder, and June grass. In this population, pollen sensitization was not related to tobacco or wood smoke exposure. Although it is widely believed that young children with asthma are most commonly allergic to indoor allergens, almost 40% of our 1- to 3-year old children with asthma showed IgE-mediated sensitivity to outdoor allergens. Pediatric allergists should consider performing skin-prick testing to their local common aeroallergens in young children with asthma and seasonal symptoms.

Spectrum of illness in pediatric common variable immunodeficiency.

BACKGROUND: Common variable immunodeficiency (CVID) may present at any age but usually presents during adulthood. OBJECTIVE: To study the presentation and associated medical conditions found in pediatric patients with CVID. METHODS: A medical record review of patients diagnosed as having CVID before the age of 18 years was performed at a tertiary care immunology clinic from 1992 to 2005. Inclusion criteria consisted of presentation with recurrent infections and decrease in 2 of 3 immunoglobulin isotypes (IgG, IgA, IgM) 2 SDs below the age-specific range, with a poor or absent response to immunization. There had to be no other identifiable predisposing cause of the immunodeficiency. RESULTS: A total of 12 patients were identified. The mean age at presentation was 8 years. All patients had low IgG levels with poor functional antibody responses. The most common presenting infections were sinusitis (75%), otitis media (67%), and pneumonia (58%). Bronchiectasis was seen in 3 children. One patient presented with chronic diarrhea due to Giardia. Two patients presented with failure to thrive. Asthma was seen in 10 patients (83%) but was usually diagnosed after the initial presentation. Autoimmune disorders were seen, including 1 patient with idiopathic thrombocytopenia and 2 with neutropenia. Other disorders encountered were growth hormone deficiency, hypothyroidism, end-stage renal disease, and sarcoma. CONCLUSIONS: CVID is a difficult diagnosis in the pediatric population because of an unpredictable presentation. Autoimmune disease, growth hormone deficiency, renal disease, and cancer were noted in our population. A high incidence of asthma also may be associated with pediatric CVID.

The pediatric board game.

A game was designed to further student learning in the field of pediatric medicine. This educational tool was designed in a board game format. Players advance through the board by answering questions correctly. A total of 400 questions were written with emphasis in content from core pediatric textbooks. Questions were created to encompass four increasingly difficult levels of play. The purpose of this study was to ascertain whether gaming can be a valuable learning experience. During clinical clerkships and rotations in pediatric medicine, both third-year medical students and residents played the game in small-group settings. To date, 37 medical students and 12 residents have completed a post-game survey with a standard 5-point Likert scale. Seven faculties have also played the game and completed the survey. The survey was designed to assess the extent to which students, residents and faculty understood the purpose of the game and agreed that it was a valuable learning experience. The data yielded descriptive statistics for preliminary evaluation of the game. The survey responses suggest that medical students, pediatric residents and faculty observed that the game was a practical and engaging learning experience. The students have universally given high scores to all 10 survey questions. The development of The Pediatric Board Game has been a successful endeavor in medical education. Both educators and learners agree that the board game is a creative and innovative educational tool. Future plans of study will help develop, refine and apply the game to advance students' knowledge of pediatric medicine.

An Internet-based pediatric clerkship examination.

A traditional paper final exam was expensive and time consuming to create, administer and grade at two separate training sites. Our goal was to determine whether restructuring the final pediatric clerkship examination using Internet technology could lower costs and be more efficient, reliable and preferred by students. Costs and coordinator time were compared with the prior year of traditional testing. Student satisfaction was determined by an electronic post-test survey. To evaluate for reliability, the scores on our Internet test were compared with United States Medical Licensing Examination (USMLE) shelf scores. An estimated 1200 US dollars per year of department costs was saved, and coordinator time was greatly reduced. The post-test survey indicated the students were very satisfied with this testing. When compared with USMLE scores the Cronbach's alpha was 0. 70, and the Pearson Correlation was r = 0.414 (p<0. 001). It is concluded that a well-designed Internet-based test has advantages over a traditional paper exam. It reduces incremental department costs, is reliable,preferred by students and can be given simultaneously at multiple locations.